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Depressive automatic processes as vulnerability markers in depression Cheung, Elsie 1991

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DEPRESSIVE AUTOMATIC PROCESSES AS VULNERABILITY MARKERS IN DEPRESSION by ELSIE CHEUNG B.A., The University of B r i t i s h Columbia, 1982 M.A., The University of B r i t i s h Columbia, 1987 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES DEPARTMENT OF PSYCHOLOGY We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA October 1991 ©Elsie Cheung, 1991 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of ?<L^CJ%ol/l<2j Lj The University of British Columbia Vancouver, Canada Date (QtT f / f / DE-6 (2/88) i i A b s t r a c t Previous r e s e a r c h has found l i t t l e support f o r c o g n i t i v e v u l n e r a b i l i t y . f a c t o r s i n d e p r e s s i o n . I argue t h a t t h i s lack of support i s due to the use of tasks t h a t tap i n t o e f f o r t f u l processes, as seen i n previous r e s e a r c h . I propose that support f o r c o g n i t i v e v u l n e r a b i l i t y f a c t o r s would be found by using tasks which tap i n t o automatic processes. Depressive automatic processes were assessed by three t a s k s : d i c h o t l c l i s t e n i n g , probe d e t e c t i o n , and i m p l i c i t memory ta s k s . For the d i c h o t l c l i s t e n i n g task, s u b j e c t s shadowed b r i e f n e u t r a l passages while d e p r e s s i o n - and p o s i t i v e - c o n t e n t words were played i n the unattended channel. C o n c u r r e n t l y , s u b j e c t s were r e q u i r e d to d e t e c t the word "press" presented i n t e r m i t t e n t l y on a computer screen. D e t e c t i o n l a t e n c i e s were recorded. For the probe d e t e c t i o n task, p a i r s of words were b r i e f l y presented on a computer screen, one appearing i n the upper h a l f of the screen, and one appearing i n the bottom h a l f . Three types of word p a i r s were used: n e u t r a l - n e u t r a l , d e p r e s s i o n - n e u t r a l , and p o s i t i v e - n e u t r a l . Subjects were asked to read the top word aloud. They were a l s o r e q u i r e d to de t e c t the presence of a •"+", which sometimes appeared i n e i t h e r l o c a t i o n of the words. De t e c t i o n l a t e n c i e s were recorded. For the i m p l i c i t memory task, h a l f of the s u b j e c t s were presented with a l i s t of words and were r e q u i r e d to r a t e each word on how much they l i k e d each word. Four types of words were used: i l l depress Ion-related, happiness-related, types o£ flowers, and types of diseases. These subjects were then asked to generate.eight exemplars for each word type. The other half of the subjects were simply asked to generate eight exemplars for the word types. Depressive e f f o r t f u l processes were defined as s e l f -report of cognitions. This was assessed by three s e l f -report questionnaires: Dysfunctional Attitude Scale, Automatic Thoughts Questionnaire, and the Hopelessness Scale. Three groups of subjects were used: currently depressed patients (n=20), remitted depressed individuals (n=20), and nondepressed Individuals (n=20). The currently depressed group consisted of 13 women and 7 men, the remitted depressed group consisted of 16 women and 4 men, whereas the nondepressed group consisted of 13 women and 7 men. Their ages ranged from 23 to 65 years, with an overall average of 39.9 (SD = 11 .28) years, subjects were tested Individually on each of the tasks. Three months after testing, they were asked to complete the Beck Depression Inventory. Four main hypotheses were examined: (a) currently depressed individuals would show a bias for depression-related stimuli on the automatic tasks; (b) remitted depressed individuals' pattern of performance on the automatic tasks would resemble that of the currently depressed patients; (c) remitted depressed Individuals' i v p a t t e r n of performance on the e f f o r t f u l tasks would resemble that of the nondepressed i n d i v i d u a l s ; and (d) measures of d e p r e s s i v e automatic processes would be p r e d i c t i v e of follow-up d e p r e s s i v e symptoms. Analyses of v a r i a n c e and r e g r e s s i o n analyses were used. The f i r s t hypothesis was not supported. The second hypothesis was o n l y supported f o r the d i c h o t i c l i s t e n i n g task. The t h i r d hypothesis was supported, whereas the f o u r t h hypothesis was not supported. I m p l i c a t i o n s of the r e s u l t s to schema theory, v u l n e r a b i l i t y methodology, and c l i n i c a l assessment procedures were d l s c u s s e d . V Table of Content A b s t r a c t 11 Table of content v L i s t of Tables . X L i s t of F i g u r e s x l L i s t of Appendices . x i i Acknowledgments x i i i Chapter 1: I n t r o d u c t i o n and overview . . . . . . 1 V u l n e r a b i l i t y to depression . . . . . 1 Overview of chapters 3 Chapter 2 : T h e o r e t i c a l and methodological i s s u e s l n re s e a r c h on c o g n i t i v e v u l n e r a b i l i t y 5 T h e o r e t i c a l i s s u e s 5 a c o g n i t i v e model o£ dtepiession , , , , 5 Depressive schema t h e o r i e s 9 Beck's schema theory . 10 Teasdale's d i f f e r e n t i a l a c t i v a t i o n theory . . . . 16 T h e o r e t i c a l p r e d i c t i o n s from schema theory . . . . 18 Methodological i s s u e s . 19 Chapter 3: Review of research on c o g n i t i v e v u l n e r a b i l i t y 25 Studies using s e l f - r e p o r t q u e s t i o n n a i r e s 26 Studies u s i n g the DAS 27 Studies u s i n g the ATQ and HS . 29 Are DAS, ATQ, and HS responses s o l e l y mood congruent? 30 Summary of DAS, ATQ,and HS s t u d i e s 32 Studies using memory measures 32 S e l f - r e f e r e n t encoding task s t u d i e s 33 v i Other memory studies 37 Summary o£ findings from memory studies 38 Studies examining d i f f e r e n t i a l relapse rates 39 Summary of status of cognitive v u l n e r a b i l i t y research . 39 Potential confounds in the cognitive v u l n e r a b i l i t y measures 40 Chapter 4: Automatic processes as v u l n e r a b i l i t y markers. 43 Definitions of automatic and e f f o r t f u l processes . . . 43 Automatic processes as potential v u l n e r a b i l i t y markers. 45 Literature review on automatic and e f f o r t f u l processes in depression . 46 D i f f e r e n t i a l effects of depression on automatic and effortful tasks 47 Automatic processing studies in depression 48 Self-referent encoding task studies . 4 9 Studies examining perceptual biases 51 Studies examining attentive biases 52 Vu l n e r a b i l i t y studies examining automatic processes , 56 Chapter 5: Statement of research problem and ove r a l l method . . . . . . . . . 58 Conceptual description of tasks used 59 Chapter 6: Method 64 Subjects . 64 Measures . . 64 DSM-III-R diagnoses 64 Schedule for Affective Disorders and Schizophrenia 65 Hamilton Rating Scale for Depression 66 v i i Beck D e p r e s s i o n I n v e n t o r y . . . . . . . . . . . . . 68 Subject c l a s s i f i c a t i o n c r i t e r i a 70 Subject c h a r a c t e r i s t i c s . . 72 Demographic and s o c i a l f a c t o r s 73 Depression data . ... . . . . . . . . 7 6 O v e r a l l procedure 78 Chapter 7 : D i c h o t l c l i s t e n i n g task 80 M e t h o d . . . . . . . . . . . . . 81 M a t e r i a l s . . . . 81 S t o r i e s 81 Unattended word 81 R e c o g n i t i o n task 83 Reaction time probe . 84 Procedure . 8 4 Hypotheses , . 87 R e s u l t s 88 Analyses . . . . . . . . . . 88 Probe r e a c t i o n time 88 C o r r e l a t i o n a n a l y s i s 90 Shadowing performance . . . . . . . . 9 2 R e c o g n i t i o n task performance 92 Summary . 9 5 Chapter 8: V i s u a l probe task 97 Method : 98 M a t e r i a l s 98 Procedure . . . . . . . . . . . . . 101 Hypotheses . 102 v l l i Results 1 0 3 Analysis 1 0 3 Missing data 103 Detection latencies 104 Summary 104 Chapter 9: i m p l i c i t memory task . 107 Method 107 Materials 107 Procedure 109 Hypotheses 110 Results I l l Analysis I l l Scoring I l l Implicit memory task 112 E x p l i c i t memory task 115 Summary 115 chapter 10: sel f - r e p o r t of cognitions 118 Method 118 Measures . 118 Automatic Thoughts Questionnaire 118 Hopelessness Scale 119 Dysfunctional Attitude Scale 120 Procedure 121 Hypotheses 121 Results 121 Analysis 121 DAS . . . . . 123 ix ATQ 123 HS 123 Summary 124 Chapter 11: Follow-up data 125 Method . 125 Materials 125 Beck Depression Inventory 125 Procedure 125 Hypothesis 126 Results 126 Analysis . 126 Subjects Who mailed the questionnaires 127 Data transformation 127 Missing data. . . 129 Regression analysis results . . . . 129 Summary ^ 131 Chapter 12: Discussion 133 Summary of findings 133 Potential limitations of work 135 Potential contributions of work . . . . . . . . ^ . . 137 References 140 X L i s t of Tables Table 1: Demographic c h a r a c t e r i s t i c s of subject groups . 74 Table 2: Depression measures at time of testing . . . . 77 Table 3: Stimulus words for dichotlc l i s t e n i n g task. . . 82 Table 4: Detection latencies from the dic h o t l c l i s t e n i n g task in msec 89 Table 5: Mean number of shadowing errors 93 Table 6: Mean number of words c o r r e c t l y recognized . . . 94 Table 7: Stimulus words for vi s u a l probe task 99 Table 8: Mean probe detection latencies, in msec 105 Table 9: Number of words generated in the i m p l i c i t task 113 Table 10: Number of words recalled ln the e x p l i c i t task 116 Table 11: Questionnaire scores 122 Table 12: Follow-up Beck Depression Inventory scores . .128 Table 13: Correlations between predictor variables with Beck Depression Inventory scores . .130 xl L i s t of F i g u r e Figure 1: Detection latencies from the dichotlc l i s t e n i n g task 91 x i i L i s t of Appendices Appendix A: Schedule for Affective Disorders and Schizophrenia . . . . 158 Appendix B: Hamilton Rating Scale for Depression . . . . 1 6 5 Appendix C: Interview probes for the Hamilton Rating Scale for Depression 172 Appendix D: Beck Depression Inventory . 176 Appendix E: DSM-III-R diagnoses for Major Depressive Episode and Dysthmia 180 Appendix F: L i s t of medications for currently and remitted depressed groups 183 Appendix G : Consent forms 185 Appendix H: Interview 188 Appendix i : stimuli for d i c h o t l c l i s t e n i n g task 190 Appendix J: Analyses of variance for di c h o t i c l i s t e n i n g task 193 Appendix K: Anaysis of variance for probe detection task 196 Appendix L: Analyses of variance for i m p l i c i t memory task 198 Appendix M: Automatic Thoughts Questionnaire 200 Appendix N: Hopelessness Scale 202 Appendix 0 : Dysfunctional Attitude Scale 205 Appendix P: Analyses of variance and covariance for the self-report questionnaires 209 Appendix Q: Correlation tables of measures by groups . . 212 x i i i Acknowledgements A thesis is never produced by a single i n d i v i d u a l . I appreciate this opportunity to acknowledge those who contributed. I would l i k e to thank Dr. R. Remick and the s t a f f of Ward West 1 of University Hospital - University of B r i t i s h Columbia s i t e for their assistance ln r e c r u i t i n g subjects. Profound thanks are extended to Jane Dunlop, whose extremely capable r e c r u i t i n g and organizational s k i l l s made thi s process a smooth one. I would l i k e to thank my thesis committee - Keith Dobson, Peter Graf, and Dimitrl Papageorgis. I am e s p e c i a l l y indebted to Peter Graf and Keith Dobson. F i n a l l y , I would l i k e to thank my family and friends, who contributed to t h i s project in I n f i n i t e ways. 1 Chapter 1: I n t r o d u c t i o n and Overview V u l n e r a b i l i t y to Depression The mental h e a l t h l i t e r a t u r e shows an e x p l o s i o n of r e s e a r c h on u n i p o l a r depression i n the past few decades. U n i p o l a r d e p r e s s i o n , the t o p i c of t h i s t h e s i s , i s d e f i n e d as d e p r e s s i o n with no p r i o r episodes of mania or hypomania. Th i s r e s e a r c h i s marked by an a i r of optimism, with some w r i t e r s summarizing i t s s t a t e as showing "true breakthroughs" (Hammen, 1985, p. 29), "tremendous progress", and " e x c i t i n g advances" (Beckham & Leber, 1985, p r e f a c e ) . To a c e r t a i n extent, such optimism i s warranted because the r e s e a r c h has l e d to h i g h l y e f f e c t i v e treatments with Impressive outcome r a t e s for both pharmacological and p s y c h o l o g i c a l approaches. Despite these ^impressive r a t e s i n the treatment of d e p r e s s i v e episodes, however, problems of c h r o n l c i t y and recurrence have l a r g e l y been Ignored. Approximately 20% of p a t i e n t s seeking treatment f o r d e p r e s s i o n do not remit, but go on to have a c h r o n i c course of d e p r e s s i o n (Klerman, 1980). Even among those s u c c e s s f u l l y t r e a t e d , the m a j o r i t y of p a t i e n t s q u i c k l y experience a r e t u r n of major symptoms. Follow-up s t u d i e s of t r e a t e d depressed p a t i e n t s have produced recurrence r a t e s as high as 16% w i t h i n one year (Kovacs, Rush, Beck, &. Hollon, 1981). Furthermore, the greater the number of previous episodes of d e p r e s s i o n , the greater the l i k e l i h o o d of r e l a p s e , with the time between r e l a p s e s l e s s e n i n g with each succeeding episode (Angst et a l . , 1973). 2 These figures suggest that once depressed, there is a strong tendency to remain in or relapse back into depression. Implicit in this is the existence of v u l n e r a b i l i t y - some di s p o s i t i o n that maintains or predisposes the individual to depression. The aim of this thesis is to address the issue of v u l n e r a b i l i t y . To provide a focus and working framework, this thesis adopts a cognitive perspective to depression. Like other researchers (e.g., Teasdale, 1988), I do not conceptualize v u l n e r a b i l i t y in purely cognitive or psychological terms. V u l n e r a b i l i t y to depression i s l i k e l y to be a complex interplay of genetic, b i o l o g i c a l , s o c i a l , and psychological factors. Nevertheless, in the absence of knowledge of s p e c i f i c relationships of these interactions, one must l i m i t one's f i e l d of inquiry. The reasons for choosing the cognitive perspective are the following. F i r s t , the cognitive model i s one of the most i n f l u e n t i a l models In research on depression at present. Second, i t d i r e c t l y addresses the issue of v u l n e r a b i l i t y , thus providing a framework for the study of v u l n e r a b i l i t y . Last, the l i t e r a t u r e provides preliminary evidence of v u l n e r a b i l i t y within a cognitive model. 3 overview of chapters In chapter 2, I review the research on cognitive v u l n e r a b i l i t y . A description of Beck and his colleagues' cognitive model (Beck, 1967, 1976; Beck, Rush, Shaw, & Emery, 1979) is f i r s t presented. In this cognitive model, depressive schemata are implicated as v u l n e r a b i l i t y factors ln depression. Next, schema and related theories are described (cf. Markus, 1977; Teasdale, 1988). On the basis of these theories, a l i s t of predictions that would be supportive of the construct v a l i d i t y of schemata Is generated. Then, research strategies used in the area of cognitive v u l n e r a b i l i t y are described and c r i t i q u e d . In chapter 3, I review the l i t e r a t u r e on cognitive v u l n e r a b i l i t y . The review is organized in terms of the measures used in the l i t e r a t u r e . These are: self-report questionnaires, memory measures, and d i f f e r e n t i a l response to cognitive therapy and pharmacotherapy. The conclusion from the review is that only weak and inconsistent support has been found. Potential confounds in the measures used are discussed. The aim of chapter 4 is to introduce the notion that depressive automatic processes are viable candidates for v u l n e r a b i l i t y factors. F i r s t , the theoretical d i s t i n c t i o n between automatic and e f f o r t f u l processes i s described. Second, research that shows that these two processes exist in depression i s outlined. Third, research on automatic 4 processes in depression is described. The l i t e r a t u r e review on automatic processes as v u l n e r a b i l i t y factors follows. in chapter 5, I provide an overview of my own empirical work. I begin with a statement of the research problem. The overa l l procedure is then described, followed by the section on subjects. In chapters 7 to 11, I describe the various parts of my, empirical work. In chapters 7 to 9, I describe the assessment of depressive automatic processing. Chapter 7 contains the results from the dichotic l i s t e n i n g task. Chapter 8 contains the results from the visual probe task, while chapter 9 contains the results from the i m p l i c i t memory task. In chapter 10, I report the assessment of the e f f o r t f u l processing, as defined by the self-report of cognitions via questionnaires. F i n a l l y , in chapter 11, I describe the follow-up data. The f i n a l chapter is the general discussion. The thesis findings are f i r s t summarized. Limitations of the findings are discussed. Last, implications of t h i s research to schema theory, v u l n e r a b i l i t y methodology, and c l i n i c a l practice are provided. 5 chapter 2: Theoretical and Methodological issues in Research on Cognitive V u l n e r a b i l i t y The aim of t h i s chapter is to provide a conceptual background for research on cognitive v u l n e r a b i l i t y . Theoretical issues are f i r s t discussed. A description of the cognitive model of depression provides the general background. More s p e c i f i c to the issue of v u l n e r a b i l i t y , depressive schemata are then described. Based on that section, a l i s t of predictions supportive of the construct v a l i d i t y of cognitive v u l n e r a b i l i t y is outlined. Next, methodological issues in cognitive v u l n e r a b i l i t y are discussed. This section is organized according to the research strategies used in the l i t e r a t u r e . Theoretical Issues  A Cognitive Model of Depression As measured by the sheer number of c i t a t i o n s , Beck and his colleagues' cognitive model (Beck, 1967, 1976; Beck, Rush, Shaw, & Emery, 1979) represents one of the most i n f l u e n t i a l psychological approaches to depression to date. Beck was among the f i r s t theorists to conceptualize unipolar depression as primarily a disorder of thinking rather than of a f f e c t . He f i r s t observed that his depressed patients are c h a r a c t e r i s t i c a l l y self-depreciating and u n r e a l i s t i c a l l y pessimistic (Beck, 1963, 1964). He further observed that these negative evaluations are often not substantiated by others and are highly resistant to refutation. To Beck, 6 th i s pattern suggested that depressed individuals suffer from distorted cognitive processes. To explain the psychological substrate of depression, the model (Beck, 1976; Beck et a l . , 1979) postulates three concepts: the cognitive t r i a d , cognitive distortions or fau l t y information processing, and schemata. The cognitive t r i a d consists of patterns of thinking that induce depressed individuals to regard themselves, their world> and their future in negative terms. The t r i a d i s manifest in the s e l f - t a l k of depressed individuals. For- example, depressed individuals often view themselves as unworthy, inadequate, and defective. They often see the world as making continuous unreasonable demands on them. They interpret th e i r interactions with the environment as representing defeat. Furthermore, depressed individuals often expect their problems to continue i n d e f i n i t e l y . When they do attempt to a l l e v i a t e their depression, they often predict f a i l u r e . The depressed individuals' tendency towards negative thinking occurs automatically, is often not substantiated by objective evidence, and stands steadfast to refutation. To explain the pervasiveness and r e s i l i e n c e of this kind of thinking, Beck postulated that depressed individuals make a series of cognitive d i s t o r t i o n s or s t y l i s t i c errors in their thinking. Examples of these are selec t i v e abstraction (the process of focusing on selec t i v e features of the si t u a t i o n , despite the presence of more s a l i e n t features) and 7 m a g n i f i c a t i o n and m i n i m i z a t i o n (a process by which negative f e a t u r e s are magnified or d i s t o r t e d , while p o s i t i v e f e a t u r e s are downplayed). Both the t r i a d and the d i s t o r t i o n s are considered to be products a r i s i n g from the operations of the schemata (Beck, 1976; H o l l o n & K r i s , 1984). Schemata are d e f i n e d as c o g n i t i v e s t r u c t u r e s which f u n c t i o n l i k e templates i n s c r e e n i n g out, coding, and I n t e g r a t i n g environmental s t i m u l i . Schema theory i s developed more f u l l y i n the next s e c t i o n . To Beck, d e p r e s s i v e c o g n i t i o n s are c e n t r a l to u n i p o l a r d e p r e s s i v e d i s o r d e r s i n two ways. F i r s t , Beck maintained that d e p r e s s i v e t h i n k i n g forms the core of depressive symptomatology (Beck, 1976; Beck et a l . , 1979). The other symptoms of d e p r e s s i o n are merely secondary m a n i f e s t a t i o n s of d e p r e s s i v e c o g n i t i o n s . The a f f e c t i v e components are d i r e c t r e s u l t s of d e p r e s s l v e s 1 ( m i s ) a p p r a i s a l of t h e i r s i t u a t i o n s . For example, i f a depressed i n d i v i d u a l e r r o n e o u s l y I n t e r p r e t s that he or she Is being r e j e c t e d , he or she would experience the sadness engendered by an a c t u a l r e j e c t i o n . M o t i v a t i o n a l aspects of depression are a l s o seen as r e s u l t i n g from d e p r e s s i v e c o g n i t i o n s . Depressed I n d i v i d u a l s become l e t h a r g i c because they p r e d i c t f a i l u r e . They r a r e l y take the i n i t i a t i v e to help themselves because they b e l i e v e t h a t they lack the personal resources to overcome t h e i r d e p r e s s i o n . F i n a l l y , the c o g n i t i v e model can help account f o r the v e g e t a t i v e s i g n s of d e p r e s s i o n . I t 8 suggests that the low energy and psychomotor retardation may r e s u l t from the f u t i l i t y experienced by depresslves' predictions that a l l efforts w i l l lead to f a i l u r e . Second, the cognitive model also views depressive cognitions as key contributing factors in the onset, maintenance, and eventual a l l e v i a t i o n of depression. Although the exact mechanisms are not c l e a r l y specified, the cognitive model postulates that schemata constitute a predisposition to depression (Beck et a l . , 1979; Kovacs & Beck, 1978). i t is assumed that negative early childhood experiences are responsible for i n i t i a l l y establishing the depressive schemata, schemata are later activated by s p e c i f i c circumstances that are analogous to the i n i t i a l experience responsible for the Inception of the schemata. For example, i f the i n i t i a l experience was the loss of a parent, then a marital separation might be the triggering event for the activation of the schema. The link between these situations might be the sense of loss of an Intimate r e l a t i o n s h i p . Once activated, the schema invokes the t r i a d and the d i s t o r t i o n s which, as discussed e a r l i e r , are the • f i r s t l inks to the other depressive symptoms. Once activated, the depressive schemata can be evoked by an increasingly wider range of s t i m u l i , even those not l o g i c a l l y related to the depressive schemata. At this point, the depressed patient's thinking appears to be dominated by negative thoughts. These thoughts may become r e p e t i t i v e and Intrusive, so that the individual has 9 d i f f i c u l t i e s sleeping or concentrating on other tasks. These read i l y accessible depressive cognitions serve to reinforce the depressed patient's b e l i e f s and predictions. This, in turn, interacts in a reciprocal feedback loop with depressive a f f e c t and other symptoms of depression u n t i l the depressed individual is caught in a continuous downward s p i r a l of depression. In severe depression, the depressive schemata eventually become autonomous. At that stage, the schemata are independent of external stimuli so that the Individual is unresponsive to changes in his or her environment. At th i s point, the depressed individual's negative cognitions and b e l i e f s appear to be v e r i d i c a l representations of r e a l i t y to the patient, even though they may appear farfetched to others or to the same individual when not depressed. When the depressed individual's "personal paradigm" Is reversed and realigned with r e a l i t y , his or her depression starts to disappear. The reversal process s p e c i f i c a l l y involves the i d e n t i f i c a t i o n and modification of depressogenic thoughts and assumptions (Beck et a l . , 1979). Depressive Schema Theories In the previous section, I describe how depressive schemata can be seen as key contributing factors to the onset and maintenance of a depressive episode. In other words, depressive schemata are central to the issue of v u l n e r a b i l i t y . This section explicates schema theory, since much of schema theory has been developed under the auspices of Beck's cognitive theory, t h i s is discussed f i r s t . Teasdale's d i f f e r e n t i a l activation theory (Teasdale, 1988), which provides an alternative but related account of schema, is then described. F i n a l l y , predictions a r i s i n g from these theories are presented. Beck's schema theory. Schemata, in general, are described as containing cognitive generalizations about the s e l f that are the culminations of past experiences (Markus, 1977). For example, a shy person's self-schema may contain the information " f e e l nervous around strangers", "am awkward with people", and "am not l i k e l y to be l i v e l y at parties", in the area of depression, the content of the depressive self-schema has been defined as containing depression-related s e l f - r e f e r e n t i a l information (Kuiper & MacDonald, 1983; Sacco & Beck, 1985), whose content can be discriminated from other nosological groups (Beck, 1967; Hollon £ Kendall, 1980 ). Depressive schemata, additionally, contain the content of the premises and assumptions associated with painful early childhood experiences (Kovacs & Beck, 1978; Sacco & Beck, 1988), For example, a depressive may have experienced an early loss of a parent. The sense of sadness and rejection engendered by the loss may result in the premise that "I must be loved in order to be happy". Another example is the premise that "unless I succeed ln everything, I am a f a i l u r e " , which may r e f l e c t the excessively high, r i g i d standards Imposed by parents in early childhood. These premises have been c a t e g o r i z e d as 11 "dysfunctional b e l i e f s " or "assumptions" (Welssman, 1980; Welssman & Beck, 1978). Although an exhaustive l i s t of these b e l i e f s has not been provided, examples are "It is important that others approve of me" and "It is not correct unless i t Is perfect" (Welssman, 1980; Welssman & Beck, 1978 ) . The self-schema has been viewed as a cognitive structure (Beck, 1976; Segal, 1988; Williams, Watts, MacLeod, & Mathews, 1988). As a structure, the Individual self-elements or constructs are organized with a high degree of i n t e r r e l a t i o n . So in the vulnerable i n d i v i d u a l , the depressive s e l f Is linked with other s e l f constructs such as se l f as mother, s e l f as spouse, and so on. It is assumed that in t h i s cognitive structure, a c t i v a t i o n of one element w i l l spread to the other elements in the structure, thereby lowering their activation thresholds (Anderson, 1983; Collins & Loftus, 1975; Higgins & Bargh, 1987). Because of this spreading of activation and the high degree of connectivity among the elements, i t is possible to activate the depressive self-schema by ac t i v a t i o n of the other neighboring self-constructs. This is consistent with Beck et a l . 's (1979) speculation, discussed in the previous section, that depressive schemata can be evoked even by stimuli not l o g i c a l l y linked to the depressive schemata. The s e l f as a cognitive structure formulation is similar to the associative network model of memory (Bower, 1981)'. Although Bower's model Is not an account of c l i n i c a l 12 d e p r e s s i o n , I t Is worth m e n t i o n i n g here as I t p r o v i d e s a v e r s i o n of the t h e o r e t i c a l groundwork f o r s c h e m a t i c I n f o r m a t i o n p r o c e s s i n g . Bower proposed t h a t the e f f e c t s of mood on c o g n i t i v e p r o c e s s e s can be i n c o r p o r a t e d w i t h i n a ge n e r a l a s s o c i a t i v e network model of long-term memory (e. g . , Anderson & Bower, 1974; C o l l i n s & L o f t u s , 1975). Bower's model assumes t h a t c o n c e p t s are r e p r e s e n t e d by i n d i v i d u a l nodes t h a t are connected t o each other by means of a s s o c i a t i o n s t h a t d i f f e r i n s t r e n g t h . Nodes t h a t are s t r o n g l y r e l a t e d i n t h e i r meanings would have s t r o n g e r l i n k s . For example, the concept " s o f t " may be r e p r e s e n t e d by a node t h a t i s s t r o n g l y a s s o c i a t e d w i t h the nodes " c u s h i o n " and "mink", and i s l e s s s t r o n g l y a s s o c i a t e d w i t h the nodes " w h i t e " or "hungry". A c t i v a t i o n of a p a r t i c u l a r node i s assumed t o l e a d t o a c t i v a t i o n of i t s connected nodes. I f the a c t i v a t i o n of these connected nodes reaches a p a r t i c u l a r t h r e s h o l d , t h e i r c o n t e n t i s made a v a i l a b l e t o c o n s c i o u s awareness. Bower a d d i t i o n a l l y proposed t h a t the number and the c o n t e n t of the r e p r e s e n t a t i o n of the nodes, a l o n g w i t h the s t r e n g t h of the a s s o c i a t i o n s , are determined by the number of p r e v i o u s e p i s o d e s and the experiences a s s o c i a t e d w i t h these e p i s o d e s . Thus, the s t r e n g t h of the a s s o c i a t i o n between " s o f t " and "mink" i s s t r o n g e r f o r a f u r r i e r than f o r a f i s h e r m a n . A l s o , the concept "snow" would have g r e a t e r r e p r e s e n t a t i o n f o r an Eskimo than f o r a Hawaiian. 13 Bower also proposed that d i s t i n c t emotions such as lioy, fear, and depression have their own nodes in memory. If depression is represented by multiple nodes with strong associations, similar experiences in the future would be more l i k e l y to correspond to a c r i t i c a l internal representation and trigger a c t i v a t i o n of the depression node, once the depression node is activated, associated similar experiences would also be activated. If the associations of these experiences are of s u f f i c i e n t strength, these experiences have the propensity to enter consciousness, bringing along their associated feelings of hopelessness and worthlessness. The network model implies that v u l n e r a b i l i t y to depression is related to previous experiences of depression. The more extensive the representation of depression ( i . e . , the greater the number of nodes d i r e c t l y connected to the depression node), the greater the likelihood of a c t i v a t i o n by similar experiences, along with the greater a c c e s s i b i l i t y to similar experiences and their associated feelings. This notion i s consistent with research that personal constructs become more organized or in t e r r e l a t e d , and thus more v e r i f i a b l e , with persistent usage (Bargh, Bond, Lombardi, & Tota, 1986; Davis & Unruh, 1981; Higgins, King, & Mavin, 1982), and with c l i n i c a l reports that the more extensive the ^experience with depression ( i . e . , the greater the number of previous episodes of depression), the greater the l i k e l i h o o d of relapse (Angst et a l . , 1973). 14 Depressive schemata provide the basis for perceiving and interpreting incoming environmental stimuli in such a manner that the f i n a l interpretation is consistent with the content of the schemata. In their drive to construe the environmental stimuli into schema-congruent information, schematic processes can produce such cognitive phenomena as memorial inaccuracies. Alba and Hasher (1983) have summarized the four operations by which the depressive schemata achieve t h i s : selection of which aspects of the incoming information are to be processed further, abstraction of the meaning of the information, interpretation which may, i f necessary, enhance or al t e r the information to be consistent with the existing knowledge structure, or to f i l l in missing d e t a i l s , and integration of the interpreted information into existing knowledge structures. Seen from the network perspective, mood may serve as a contextual cue, p r e f e r e n t i a l l y activating associations in the network that are congruent with the mood state. Schematic processing should be evident as attentive and memorial biases for depression-related s t i m u l i , along with t h e i r associated cognitive products ( i . e . , depressive thoughts). C l a s s i f i e d d i f f e r e n t l y , schemata processing encumbers both automatic (selection and abstraction) and e f f o r t f u l (interpretation and I n t e g r a t i o n ) processing (Hasher & zacks, 19 79; S c h l f f r i n & Schneider, 19 7 7 ) . The relevance of this c l a s s i f i c a t i o n w i l l be explained l a t e r . 15 As d i s c u s s e d e a r l i e r , d e p r e s s i v e schemata predispose i n d i v i d u a l s to depression. However, the p r e c i s e manner i n which t h i s occurs i s c o n t r o v e r s i a l . On the one hand, d e p r e s s i v e self-schemata have a t r a i t l i k e q u a l i t y : [Tlhese schemas are long-term, i d e n t i f i a b l e p s y c h o l o g i c a l patterns t h a t Influence a t t i t u d e and b e h a v i o r a l responses [and] they may c o n s t i t u t e a c o g n i t i v e dimension of the depression-prone i n d i v i d u a l ' s p e r s o n a l i t y (Kovacs & Beck, 1978, p. 525, emphasis mine). Thus, Beck's maladaptive s e l f - r e f e r e n t schemata are seen as enduring c o g n i t i v e c h a r a c t e r i s t i c s t h at can be measured and used as an i n d i c a t o r of i n d i v i d u a l s who are prone to depress i on. But another account of how a d e p r e s s i v e episode i s I n i t i a t e d e x i s t s . Depressive schemata are c o g n i t i v e s t r u c t u r e s which remain l a t e n t u n t i l r e v e a l e d under p a r t i c u l a r c o n d i t i o n s : These negative concepts (schemas) may be l a t e n t but can be a c t i v a t e d by s p e c i f i c circumstances which are analogous to the experiences I n i t i a l l y r e s p o n s i b l e f o r embedding the negative a t t i t u d e s (Beck et a l . , 1979, p. 16) . Hence, schemata are only r e v e a l e d d u r i n g a d e p r e s s i v e episode. 16 Teasdale'g d i f f e r e n t i a l a c t i v a t i o n theory. Unlike Beck and h i s c o l l e a g u e s , Teasdale (1988) viewed the question of why i n d i v i d u a l s become depressed as not c r i t i c a l . To Teasdale, d e p r e s s i o n i s a normal r e a c t i o n to adverse circumstances. However, the usual course i s that of f a i r l y r a p i d r e c o v e r y . The v u l n e r a b l e i n d i v i d u a l s are those who go on to have d e p r e s s i o n of s u f f i c i e n t s e v e r i t y and c h r o n i c i t y to warrant a c l i n i c a l d i a g n o s i s of d e p r e s s i o n . The c r i t i c a l q u e s t i o n , t h e r e f o r e , i s not why i n d i v i d u a l s become depressed, but why some go on to have severe and p e r s i s t e n t d e p r e s s i o n . V u l n e r a b i l i t y to severe and p e r s i s t e n t d e p r e s s i o n , a c c o r d i n g to Teasdale's d i f f e r e n t i a l a c t i v a t i o n theory, i s r e l a t e d to d i f f e r e n c e s i n p a t t e r n s of t h i n k i n g that are a c t i v a t e d once the I n d i v i d u a l i s i n the depressed s t a t e . V u l n e r a b l e i n d i v i d u a l s , Teasdale t h e o r i z e d , are c h a r a c t e r i z e d as those i n t e r p r e t i n g events as h i g h l y a v e r s i v e and u n c o n t r o l l a b l e (Teasdale, 1985). T h i s p a t t e r n of t h i n k i n g can be a c t i v a t e d e x t e r n a l l y by environmental s t i m u l i such as s t r e s s f u l events, or i n t e r n a l l y by a c t i v a t i o n of the r e p r e s e n t a t i o n s i n memory of events so i n t e r p r e t e d . A c t i v a t i o n could be f u r t h e r f u e l l e d by ruminations r e l a t e d to c u r r e n t or past d e p r e s s i n g experiences ( F e n n e l l , Teasdale, Jones, & Damle, 1987). The tendency towards depressogenic i n t e r p r e t a t i o n s Is a j o i n t f u n c t i o n of the nature of the experience and the s t a t e of the i n f o r m a t i o n p r o c e s s i n g system t h a t i n t e r p r e t s them. 17 The l a t t e r aspect Influences Information processing on two leve l s : the type of information that is selected for attention, and which interpretative categories are highly primed and, thus, are most l i k e l y to be used to interpret experience. These are similar to schematic operations. Furthermore, the type of information that is processed w i l l be a function of both what is available in memory and what is most accessible at a given time. For example, in nonvulnerable individuals, what becomes accessible are r e l a t i v e l y mild negative se l f - d e s c r i p t o r s such as "thoughtless", "inconsiderate", and "rude". In vulnerable individuals, a more global negative view of s e l f becomes accessible with such globally negative descriptors, including label such as "worthless", "no good", and "pathetic". Teasdale argues that once this system of depressogenic cognitive processing biases becomes activated, the negative thoughts themselves tend to exacerbate and prolong the disturbed mood. Nolen-Hoeksema and her colleagues (Morrow & Nolen-Hoeksema, 1990; Nolen-Hoeksema, 1987) outlined three ways In which negative cognitions could amplify and prolong a depressed mood. F i r s t of a l l , in search for the reasons behind th e i r depressed mood, depressed individuals (by virtue of their depressed mood) are more l i k e l y to make negative Inferences. Second, ruminations over their depression can enhance the ef f e c t of ex i s t i n g maladaptive cognitions by bringing these cognitions to the individual's 18 mind more often. F i n a l l y , ruminations can undermine active coping by i n t e r f e r i n g with the attention, concentration, and the i n i t i a t i o n of instrumental behavior. The inattentiveness and behavioral d e f i c i t s may lead to f a i l u r e s which lead to a greater sense of helplessness, thereby contributing to the depression. This vicious cycle of depression, negative cognition, depression eventually results in a depression of s u f f i c i e n t intensity and duration to warrant a c l i n i c a l diagnosis. At f i r s t glance, the two accounts of v u l n e r a b i l i t y may appear quite d i f f e r e n t . The central difference between them is the locus of the v u l n e r a b i l i t y , that Is, onset versus maintenance. However, Teasdale's way of thinking about what characterizes vulnerable individuals is akin to Beck's conceptualization of schema operations. Indeed, one of the studies v a l i d a t i n g Teasdale's d i f f e r e n t i a l activation theory used schematic measures (Dent & Teasdale, 1988). Theoretical predictions from schema theory. In the previous section, two versions were presented on how schemata predispose vulnerable individuals to depression. These lead to d i f f e r e n t predictions supportive of the construct v a l i d i t y of cognitive v u l n e r a b i l i t y . To b r i e f l y r e i t e r a t e , the f i r s t version is that depressive s e l f -schemata have a t r a i t l i k e c h a r a c t e r i s t i c (Kovacs & Beck, 1978).. Thus, schemata are observable independent of a depressive episode and are markers for those prone to 19 depression. Theoretical predictions consistent with t h i s viewpoint are: (a) Depressive schemata are not only evident during a depressive episode, but also prior to and after the recovery from a depressive episode. Thus, depressive schemata are evident even in recovered depressives. (b) Measures of depressive schemata are related to and predictive of the l i k e l i h o o d of developing a depressive episode in some time in the future. The second viewpoint is that depressive schemata are latent u n t i l "switched on" by a depressive episode (Beck et a l . , 1979; Teasdale, 1988). Thus, (c) Measures of the depressive schemata are predictive of the severity and chronicity of a depressive episode. An additional prediction i s : (d) The strength of the depressive schemata Is related to the number of previous episodes of depression (Corollary of Bower's [1982] model). Methodological Issues In this section, I review the various research strategies that have been used to examine cognitive v u l n e r a b i l i t y . The advantages and disadvantages of each strategy are outlined. In discussing theories of v u l n e r a b i l i t y , several researchers (Depue & Monroe, 1986; Lewlnsohn, Hoberman, Te r i , & Hautzinger, 1985; Monroe & Steiner, 1986) have argued for the necessity of distinguishing factors related to the onset of a d e p r e s s i v e episode and f a c t o r s t h a t determine the c h r o n i c i t y and s e v e r i t y of a d e p r e s s i v e episode. Some have even argued that d i f f e r e n t models are needed f o r the study of how a d i s o r d e r i s i n i t i a t e d and how a d i s o r d e r i s maintained over time (Depue & Monroe, 1 9 8 6 ; Monroe & s t e i n e r , 1 9 8 6 ) . L i k e w i s e , r e s e a r c h s t r a t e g i e s i n the c o g n i t i v e v u l n e r a b i l i t y l i t e r a t u r e can be d i v i d e d Into those which address onset v u l n e r a b i l i t y and those which address v u l n e r a b i l i t y to p e r s i s t i n g d e p r e s s i o n . The bulk of the c o g n i t i v e v u l n e r a b i l i t y r e s e a r c h has attempted to address onset v u l n e r a b i l i t y . I m p l i c i t i n t h i s l i n e of r e s e a r c h i s the view t h a t depressive schemata have a s t a b l e c h a r a c t e r i s t i c t h a t i s evident p r i o r to, and p e r s i s t s beyond a depressive episode. Research along t h i s l i n e has taken one of four s t r a t e g i e s , each d i f f e r i n g i n the degree of d i r e c t n e s s i n t e s t i n g onset v u l n e r a b i l i t y . The f i r s t s t r a t e g y i s designed to d i r e c t l y address the issue of onset v u l n e r a b i l i t y . I t i s a p r o s p e c t i v e approach that Involves f o l l o w i n g a group of I n i t i a l l y nondepressed i n d i v i d u a l s over a course of time to o b t a i n a subgroup of depressed i n d i v i d u a l s (e.g., Hammen, Marks, deMayo, & Mayol, 1 9 8 5 ; Lewlnsohn, steinmetz, Larsen, & F r a n k l i n , 1 9 8 1 ; O'Hara, 1 9 8 6 ; P h i f e r & M u r r e l l , 1 9 8 6 ) . Researchers need to ensure t h a t they have a t r u l y premorbid sample by a c a r e f u l s c r e e n i n g of l i f e t i m e prevalence of p s y c h i a t r i c diagnoses i n each s u b j e c t . Measures of premorbid f u n c t i o n i n g are then compared between those i n d i v i d u a l s who become depressed with 21 those who remain nondepressed. It is argued that differences between these two groups in the premorbid variables become l i k e l y candidates for onset v u l n e r a b i l i t y factors. The great advantage of t h i s design is that the premorbid status can be determined prior to a depressive episode. However, this design may be subject to sampling error. Researchers have generally administered the follow-up depression measures at one point in time.. These researchers assumed that individuals who are nondepressed at follow-up are nonvulnerable i n d i v i d u a l s . However, these individuals may become depressed at some future time beyond the follow-up date, or they may have had a depressive episode during the time between i n i t i a l assessment and follow-up, but have recoved prior to follow-up time. Furthermore, the p r a c t i c a l constraints of the large sample size and the long time lag required to ensure an adequate f i n a l sample of depressed subjects, along with the enormous cost, contribute to the s c a r c i t y of research of t h i s type. The second research strategy addresses onset v u l n e r a b i l i t y i n d i r e c t l y by establishing the s t a b i l i t y of depressive cognitions. In general, researchers using this strategy have assessed individuals during a depressive episode and retested them upon recovery (e.g., Dobson & Shaw, 1987). In demonstrating that depressive cognitions remain stable with the a l l e v i a t i o n of depression, these researchers argued that these cognitions are not merely symptoms of a depressive episode. Their t r a i t l i k e 22 ch a r a c t e r i s t i c s have generally been taken as evidence of their status as marker of v u l n e r a b i l i t y . This strategy, however, presents an ambiguity in interpreting the r e s u l t s . It Is impossible to determine whether the cognitive variables were present prior to the depressive episode and, hence, are candidates for onset v u l n e r a b i l i t y factors, or become present by virtue of having experienced a depressive episode and as such, are consequences or "scars" (Lewlnsohn et a l . , 1981) of a depressive episode. In addition, the time of measurement may be c r i t i c a l . Should a researcher measure just upon recovery or wait some time after recovery? The former approach may result in misleading conclusions because i t is possible that there is a desynchrony of depressive symptoms, analogous to the desynchrony of symptoms with the a l l e v i a t i o n of fear (Lang, 1977, 1979). That i s , there may be a difference in the rate of change among the symptoms of depression, with the cognitive aspects being among the slowest to show change. The third strategy that addresses onset v u l n e r a b i l i t y Is a variant of the second strategy, instead of a longitudinal design, this strategy en t a i l s a between-groups comparison between recovered depressed individuals with nondepressed controls. Assuming that depressive schemata are stable markers of v u l n e r a b i l i t y , recovered depresslves (who have expressed their v u l n e r a b i l i t y by having experienced a depressive episode) should show scores on measures of depressive schemata similar to that of currently 23 depressed individuals. For the same reasons as for the previous design, this design cannot d i r e c t l y address the issue of onset v u l n e r a b i l i t y . The fourth strategy involves reframing the v u l n e r a b i l i t y issue into one of predictive v a l i d i t y . It i s based on the premise that depressive schemata, as v u l n e r a b i l i t y markers, should be predictive of relapse. Investigators using this strategy t y p i c a l l y select subjects vho have just been successfully treated for their depression and based on their cognitive status at that time, predict the l i k e l i h o o d of relapse at some future point of time (e.g., Hollon, Evan, & DeRubeis, 1988; Simon, Murphy, Levine, & Wetzel, 1986). One advantage of t h i s design is i t s external v a l i d i t y . That i s , one of the d e f i n i t i o n s of v u l n e r a b i l i t y is a predisposition towards depression. Thus, the prediction of relapse is a r e l a t i v e l y d i r e c t assessment of v u l n e r a b i l i t y , one disadvantage in t h i s strategy is i t s potential confound with poor response to treatment. This type of research predicts relapse on the basis of posttreatment cognitive measures. However, the cognitive measures may be r e f l e c t i v e of poor or Incomplete response to treatment which, in turn, may be r e f l e c t i v e of a more resi s t a n t type of depression. In each of these three strategies, demonstration of the s t a b i l i t y of the cognitive variable is not necessarily evidence of v u l n e r a b i l i t y . It is possible that these variables constitute stable aspects of vulnerable Individuals which have no impact on depression. The challenge would s t i l l remain in demonstrating how these variables contribute to the onset, maintenance, and a l l e v i a t i o n of depression. strategies can also be c l a s s i f i e d into those which address v u l n e r a b i l i t y to persisting depression. The central question in research using this strategy is which variables determine the chronicity and severity of a depressive episode. Research of this nature has assessed the cognitive status of subjects who are i n i t i a l l y mildly depressed and then, assessed levels of depression at some future time (e.g., Dent & Teasdale, 1988). Instead of asking which variables amplify a depressive episode as ln the previous research strategy, some researchers have examined which variables serve as an impediment to recovery. Such studies have used cognitions to predict response or resistance to treatment (e.g., Ke l l e r , 1983). in summary, researchers have used a variety of research strategies to address cognitive v u l n e r a b i l i t y . Generally, these strategies can be c l a s s i f i e d into those which address onset v u l n e r a b i l i t y and those which address v u l n e r a b i l i t y to persis t i n g depression. Although the literature, review, presented in the next chapter, is divided along the lines of the methods used, a l l of the methods used the majority of these strategies. 25 Chapter 3: Review of the Research on Cognitive V u l n e r a b i l i t y Whereas the previous section has categorized the l i t e r a t u r e in terms of research strategies, this chapter is organized in terms of the measures used. For the most part, studies addressing cognitive v u l n e r a b i l i t y have used s e l f -report questionnaires, memory measures, and d i f f e r e n t i a l response to cognitive therapy and pharmacotherapy. In reviewing the l i t e r a t u r e , two inclusion c r i t e r i a were used. F i r s t , in order to provide a focus, only those measures t h e o r e t i c a l l y t i e d to Beck et al.'s (1979) model were Included. Second, th i s review was limited to studies using samples defined by c l i n i c a l and/or research diagnosis such as DSM-III or Research Diagnostic C r i t e r i a , and excluded those studies using analogue samples such as college students c l a s s i f i e d as "depressed" solely on the basis of their scores on the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). The reason for the second c r i t e r i o n is the following. Recently, serious reservations have been raised on the g e n e r a l i z a b i l l t y and a p p l i c a b i l i t y of analogue studies using mildly dysphoric college students to the phenomenon of c l i n i c a l depression. Coyne and Gotlib (1983) and Depue and Monroe (1978) detailed the reasons why It is unwise to combine such analogue studies with research on depressed patient samples. Analogue samples are further removed from the construct of Interest and, thus, do not offer the most 26 d i r e c t test. Furthermore, the experimental variables may be s p e c i f i c to unipolar depression and, thus, may not be present in analogue samples. Studies Using Self-Report Questionnaires The bulk of the cognitive v u l n e r a b i l i t y research has used self-report questionnaires, perhaps because of their sheer ease of administration. Since t h i s thesis uses Beck and his colleagues' cognitive framework, i t w i l l focus only on those questionnaires e x p l i c i t l y developed under that framework. These are: the Dysfunctional Attitude Scale (DAS; Weissman, 1978), the Automatic Thoughts Questionnaire (ATQ'; Hollon & Kendall, 1980), and the Hopelessness Scale v (HS; Beck, Weissman, Lester, & Trexler, 1974). The DAS purports to measure dysfunctional attitudes -- cognitions t h e o r e t i c a l l y seen as stable aspects of vulnerable individuals, while the HS and the ATQ assess automatic thoughts - - c o g n i t i o n s seen as symptomatic of depression. Despite t h i s t h e o r e t i c a l d i s t i n c t i o n of t r a i t versus state aspects^of depressive cognitions, some researchers have treated a l l three measures as equal candidates for cognitive v u l n e r a b i l i t y factors. For example, Wilkinson and Blackburn's (1981) central question ln their study was "Do [recovered depressives] exhibit t h i s [cognitive] style when their i l l n e s s i s in remission?" (p. 284), and they j u s t i f i e d the use of the HS as an appropriate method of measurement since "tt.lo date i t is probably the best validated measure of cognitive s t y l e " (p. 284). 27 Studies Using the DAS Many Investigations have used the DAS as an index of v u l n e r a b i l i t y to depression, studies comparing DAS scores taken during a depressive episode and at remission have, for the most part, f a i l e d to support the notion of dysfunctional attitudes as stable aspects of vulnerable individuals. Most studies of this nature have found that DAS scores endorsed by remitted depressed individuals were comparable to those endorsed by nondepressed control subjects (Blackburn, Jones, & Lewin, 1987; Dohr, Rush, & Bernstein, 1989; Hamilton & Abramson, 1983; Hollon, Kendall, & Lumry, 1986; Reda, C a r p l n i e l l o , S e c c h i a r l l , & Blanco, 1985; Schrader, Gibbs, & Harcourt, 1986; Silverman, Silverman, & Eardley, 1984; Simons, Garfield, & Murphy, 1984). Only two studies have shown that DAS scores from remitted depressed patients were elevated in comparison to nondepressed controls (Dobson & Shaw, 1986; Eaves & Rush, 1986). The discrepancy in the results may be accounted for by the length of time of symptom remission. Unfortunately, many of these studies do not provide estimates of duration of remission. But among the studies providing such estimates, i t is interesting that short periods of remission are associated with elevated DAS scores (Eaves & Rush, 1984, 2-3 weeks), whereas longer periods are associated with DAS scores within the normal range (Reda et a l . , 1985, 1 year; Schrader et a l . , 1986, > 1 year; Silverman et a l . , 1984, > 1 28 month; Simons et a l . , 1984, > 1 month). This raises the p o s s i b i l i t y that elevated DAS scores are only present in r e l a t i v e l y recently remitted patients. It would appear that long-term remitted individuals are not characterized by overa l l elevated DAS scores. However, closer inspection on s p e c i f i c dysfunctional attitudes yields more illuminating r e s u l t s . Reda et a l . (1985) administered a modified version of the DAS upon hospital admission, at discharge, and at 1 year following discharge. At follow-up, the recovered depressed group's ov e r a l l DAS scores did not d i f f e r s i g n i f i c a n t l y from the control group. However, 13 of the DAS b e l i e f s discriminated the recovered group from the nondepressed group, even at 1 year follov-up. Furthermore, five of these b e l i e f s seemed to be very resistant to change: Patients persisted in endorsing these b e l i e f s , despite their nondepressed status at 1 year follow-up. These b e l i e f s related to a pessimistic outlook, a f e l t need for control over their situations and feelings, along with a reluctance to seek help from others, an overemphasis on others' judgments and opinions, and the sense that they should have the a b i l i t y to solve their problems quickly, independently, and e a s i l y . i n t r i g u i n g findings have also come from the prospective studies. Rush, Welssenburger, and Eaves (1986) attempted to predict the outcome of patients following their remission from depression. At 6 months follow-up, the DAS was the best predictor of depression status (as assessed by the Hamilton Rating Scale for Depression and c l i n i c a l evaluations based on Research Diagnostic C r i t e r i a ) , accounting for 25% of the variance. In a similar vein, Simons, Murphy, Levine, and Wetzel (1986) found that DAS scores, along with s o c i a l adjustment, were predictive of relapse at 1 year posttreatment. Instead of predicting relapse, Dent and Teasdale (1988) predicted the persistence of depression. Along with other cognitive measures, the DAS was predictive of depressive symptoms (as assessed by the Beck Depression Inventory and Research Diagnostic C r i t e r i a diagnosis) at 5 months follow-up in a sample of untreated women from the community. F i n a l l y , dysfunctional attitudes may hinder the a l l e v i a t i o n of depression. Keller (1983) found that subjects with higher i n i t i a l levels of dysfunctional attitudes showed poorer response to cognitive therapy. This rela t i o n s h i p held even when pretreatment depression scores were controlled for. Studies Using the ATQ and HS The majority of the studies using the ATQ and the HS support the notion that automatic thoughts are symptomatic of depression. The majority of the studies using recovered depressives have found that their scores obtained from the ATQ and HS were comparable with those of the nondepressed control group (HS: Dobson & Shaw, 1986; Hamilton & Abramson, 1983; Wilkinson & Blackburn, 1981. ATQ; Dohr et a l . , 1987; Eaves & Rush, 1984; Hollon, Kendall, & Lumry, 30 1986), Furthermore, Rush, weissenburger, and Eaves (1986) found that A T Q scores were not predictive of depressive symptoms at 6 months follow-up. However, two studies contradict this trend. Dobson and Shaw (1986) found that remitted depressed patients endorsed a higher proportion of automatic thoughts than the nondepressed control subjects. Additionally, Dohr et a l . (1987) found that remitted depressives endorsed more hopelessness items than nondepressed control subjects. It is unclear whether the l a t t e r two studies employed patients who had just recently recovered. Are D A S , ATQ, and HS Responses Solely Mood Congruent? So far, the majority of the studies have shown that remitted scores on the D A S , ATQ, and HS are comparable to those of nondepressed controls. This trend raises the question whether the subjects endorse items that are congruent with their mood state. That i s , depressed subjects may be endorsing depressogenic items simply in response to their negative tone. Three studies suggest that endorsement of negative items is not e n t i r e l y a r e f l e c t i o n of depressed mood. Hamilton and Abramson (1983) found that approximately 1/2 of their depressed sample achieved scores In the normal range on a number of cognitive questionnaires, which included the DAS and H S . This suggests that depressed mood, by i t s e l f , i s not s u f f i c i e n t to induce a depressive cognitive s t y l e . 31 Robins, Block, and Peselow (1990) compared DAS scores endorsed by endogeneous with non-endogenous depresslves. Simply stated, endogenous depressions are assumed to be primarily b i o l o g i c a l l y determined, whereas non-endogenous depressions are assumed to occur in reaction to l i f e stressors, e s p e c i a l l y in individuals with certain types of premorbid personality (Klloh & Garslde, 1963) . The l a t t e r type Is assumed to be characterized by a depressive cognitive s t y l e . Even though the endogenous depresslves had higher scores on measures of depression than the non-endogenous depresslves, the l a t t e r had higher DAS scores, in other words, there is not an one-to-one correspondence between severity of depressed mood and DAS scores. F i n a l l y , Miranda and Person (1988) assessed performance on the DAS following an induction of sad mood using the Velten technique (Velten, 1968) . This technique involves reading aloud 60 negative s e l f - r e f e r e n t statements. I f endorsement of negative items on self-report questionnaires are merely a mood congruency e f f e c t , then successful induction of depressed mood would lead to a higher endorsement rate. Two groups of subjects with no prior history of depression and those with a history of depression were both successfully induced into a sad mood. However, only those subjects with a previous history of depression endorsed more dysfunctional attitudes following the mood Induction. 32 Summary of DAS, ATQ, and HS Studies This c o l l e c t i o n of studies suggest the following conclusions. Endorsement of depressive cognitions questionnaires are probably not s o l e l y mood dependent. The cognitive model is not r e l i a b l y predictive of which types of cognitions are t r a i t l i k e and which are symptomatic of depression. A few studies have found negative automatic thoughts to be elevated in remitted depressed Individuals, but the majority of studies suggest that these return to normal leve l s in remission. Dysfunctional attitudes, hypothesized to be stable aspects, may s t i l l be evident for newly remitted patients, but may be altered as the patient continues to stay in remission. Group-means comparison of these questionnaire responses generally yielded nonsupportlve re s u l t s , on the other hand, the longitudinal study of remitted depressed subjects provides much more promising r e s u l t s , with dysfunctional attitudes r e l i a b l y predictive of future dysphoria and relapse. Studies Using Memory Measures In a previous section, I discuss the importance of self-schemata in depressive v u l n e r a b i l i t y . Also as discussed previously, the influence of the depressive s e l f -schemata is made evident by memorial biases for depression-related s t i m u l i . Thus, a reasonable point of inquiry for v u l n e r a b i l i t y research would be In the memory studies. Memory studies, which address v u l n e r a b i l i t y , can be divided into two groups: those using the s e l f - r e f e r e n t encoding task, and those using other paradigms. Self-Referent Encoding Task Studies The self-referent encoding task (SRET) was s p e c i f i c a l l y designed to assess schemata (cf. Markus, 1977). in the SRET, subjects t y p i c a l l y are asked to rate a l i s t of adjectives as self-descriptive or not. In the research on depressive self-schema, researchers have used depression-related (schema-congruent) and positive (schema-lncongruent) adjectives. Decision latencies for these judgments are recorded. Following the judgment task, an incidental r e c a l l task i s given. The SRET produces three indexes: endorsement rate for the adjectives, decision latencies for judgments, and r e c a l l of adjectives. Schema theory predicts that individuals are: (a) more l i k e l y to endorse schema-congruent adjectives as s e l f - d e s c r i p t i v e , (b) process schema-related items more e f f i c i e n t l y as reflected by shorter decision latencies, and (C) r e c a l l a higher proportion of schema-congruent adjectives. Endorsement rates should be symptomatic of depression, whereas the r e c a l l and decision latencies indexes for depression-related stimuli are theorized to be more stable aspects of depression (cf,. Myers, Lynch, & Bakal, 1987). In the area of depression, Kuiper and his colleagues (Derry & Kuiper, 1981; Kuiper & MacDonald, 1983) were among the f i r s t researchers to use the SRET to measure depressive self-schema. They found that depressed individuals had 34 higher endorsement rates, shorter decision latencies, and enhanced r e c a l l for depression-related adjectives. Dobson and Shaw (1987) attempted to assess the s t a b i l i t y of the depressive schemata in a longitudinal design. Depressed patients were given the SRET twice. The f i r s t testing session was conducted during a depressive episode. A subset of this depressed group were retested while they were s t i l l depressed, whereas the other subset was retested upon symptom remission. The subjects who remained depressed showed consistent performance on the SRET across the two testing occasions, demonstrating at least adequate t e s t - r e t e s t r e l i a b i l i t y of the SRET. However, the investigators found a s h i f t in SRET performance in the remitted depressed patients. The investigators concluded that "[t]he results of the present study must tentatively be added to the number of studies that have f a i l e d to document stable cognitive processing in depressive episodes and beyond" (p. 39). However, Dobson and Shaw's conclusion seems premature. It appears that they were only able to partly demonstrate evidence of depressive schematic processing. Although they were able to demonstrate that symptomatic depresslves endorsed more negative adjectives as s e l f - d e s c r i p t i v e , compared with the nondepressed controls, they were not able to demonstrate depressed-nondepressed group differences in either decision latencies or in r e c a l l for the di f f e r e n t types of words. It i s not surprising, although 35 t h e o r e t i c a l l y uninteresting, that the endorsement rate3 changed as a function of recovery. More t h e o r e t i c a l l y Interesting measures attesting to the s t a b i l i t y of the depressive self-schema l i e In the decision latencies and r e c a l l measures. The f a i l u r e to demonstrate depressed-nondepressed group differences on those measures seriously undermines the power of t h i s study in illuminating the issue of v u l n e r a b i l i t y . Bradley and Mathews (1988) were able to demonstrate memorial biases using the SRET. Their group of currently depressed patients showed the predicted negative r e c a l l bias for material that had been encoded in r e l a t i o n to themselves. They then tested the cognitive v u l n e r a b i l i t y hypothesis by including a group of recovered depressed patients. The recovered group resembled the nondepressed group in favoring positive s e l f - r e f e r e n t material. However, an unexpected r e s u l t was also found (as reported in Brewln, 1988). Currently depressed patients who were not included in the study because they had a previous manic episode or because they had undergone cognitive therapy, f a i l e d to show a negative s e l f - r e f e r e n t r e c a l l bias. This raises two intriguing p o s s i b i l i t i e s : f i r s t , the depressive schema may be s p e c i f i c to unipolar depression, and second, responses to Cognitive Therapy — a therapy purporting to a l t e r underlying dysfunctional b e l i e f s — may be reflected in changes in the depressive self-schema. 3 6 Teasdale and Dent (1987) compared the r e c a l l o£ recovered depressed with never depressed Individuals. Although both groups recalled equal amounts of negative material, the recovered depressed subjects d i f f e r e d from the never depressed subjects in that they recalled fewer positive adjectives, suggesting reduced ac t i v a t i o n of positive aspects of the self-schema. This difference held, even when i n i t i a l depression levels were controlled for. These investigators then went on to test their d i f f e r e n t i a l a c t i v a t i o n hypothesis according to which, negative aspects of the self-schema become accessible only when the vulnerable i n d i v i d u a l Is in a depressed mood. They Induced a 3ad mood in their two groups. Under the induced sad mood, the recovered depressed subjects showed better r e c a l l of s e l f - r e f e r e n t i a l negative adjectives than the never depressed in d i v i d u a l s . Along si m i l a r l i n e s , Dent and Teasdale (1988) asked whether measures of the depressive self-schema would be related to the persistence of depressed mood. Using Diagnostic Research C r i t e r i a to identify a group of ^ untreated depressed women from the community, these investigators correlated self-schema measures with their depression measures at 5 months follow-up. At follow-up, high depression scores were related to the endorsement rate and r e c a l l of negative but not positive terms. This study provides preliminary evidence that negative aspects of the 37 self-schema are instrumental in the persistence of depression. Other Memory Studies Although not e x p l i c i t l y under the framework of schema theory, three studies addressing v u l n e r a b i l i t y used memory measures. S l i f e , Miura, Thompson, Shapiro, and Gallagher (1984) followed three groups of elderly depresslves undergoing behavioural, cognitive, and psychodynamlc treatments for depression. Patients' r e c a l l of pleasantly-rated trigrams was assessed on three occasions: prior to the i n i t i a t i o n of therapy, midway through, and after termination. Prior to the i n i t i a t i o n of therapy, depressed patients recalled more trigrams that they rated as d i s l i k e d than those they rated as l i k e d , upon recovery following successful therapy, these patients recalled more trigrams that they rated as l i k e d . It is d i f f i c u l t to determine whether these results are supportive of cognitive v u l n e r a b i l i t y theory. Cognitive therapy, but not the other two therapies, has t h e o r e t i c a l l y the propensity to a l t e r depressive schemata, hence leading to enhanced r e c a l l of the liked trigrams as therapy progressed. Whether th i s outcome occurred can not be assessed, however, because the Investigators did not conduct separate analyses on the r e c a l l performance in each treatment modality. The other two studies have yielded nonsupportive r e s u l t s . In a longitudinal design, Fogarty and Hemsley (1983) asked subjects to r e c a l l past real l i f e experiences 38 associated with a series of stimulus words. The depressed patients, compared to the nondepressed subjects, showed a greater probability of r e c a l l i n g sad memories. Among the depressed patients who showed c l i n i c a l Improvement at 6 weeks retestlng, the pattern of r e c a l l had shifted. They had a s i g n i f i c a n t reduction in the r e c a l l of sad memories and an increased probability of producing happy memories. in a variation of thi s theme, Lewlnsohn and Rosenbaum (1987) examined whether the r e c a l l of certain parental behavior is a stable c h a r a c t e r i s t i c of depressed i n d i v i d u a l s . Depressed individuals recalled their parents as r e j e c t i n g and unloving, compared to nondepressed controls. The remitted depresslves, however, did not d i f f e r from the nondepressed controls in their r e c a l l of parental behavior. The investigators concluded that the r e c a l l of parental behavior was not a stable aspect of depression. Since t h i s study did not provide checks on actual parental behavior, i t is impossible to ascertain whether memory biases are at play here. summary of Findings from Memory Studies The results of the memory studies p a r a l l e l the results from the questionnaire studies. Between-groups comparisons, either ln a longitudinal approach or In comparing recovered with currently depressed subjects, yielded nonsupportive r e s u l t s . In terms of predictive u t i l i t y , however, the memory research holds some promise. 39 Studies examining D i f f e r e n t i a l Relapse Rates Some of the strongest and most consistent evidence of cognitive v u l n e r a b i l i t y comes from the relapse l i t e r a t u r e . Simons, Murphy, Levine, and Wetzel (1986) followed depressed patients 1 year after successful treatment of their depression. In support of the v u l n e r a b i l i t y model, cognitive factors were predictive of the p r o b a b i l i t y of relapse. Patients who relapsed had s i g n i f i c a n t l y higher DAS scores at treatment termination. Furthermore, patients who had received Cognitive Therapy, with or without combined drug treatment, were less l i k e l y to relapse than patients who had received pharmacotherapy alone. The l a t t e r finding has been replicated by at least two other Independent studies (Blackburn, Eunson, & Bishop, 1986; Hollon, Evans, & DeRubels, 19 88). Summary of status of Cognitive V u l n e r a b i l i t y Research Despite the methodological d i f f i c u l t i e s associated with some of the studies, two trends emerge, studies using f a c t o r i a l designs (e.g., comparing scores during a depressive episode and upon recovery, comparing groups of currently depressed and recovered depressed subjects) have, in general, yielded nonsupportive r e s u l t s . However, studies concerned with prediction (predicting course of depression, response to treatment, p r o b a b i l i t y of relapse) have yielded consistently supportive findings. The apparent discrepancy may l i e in d i f f e r e n t i a l s t a t i s t i c a l power associated with each design. The f a c t o r i a l designs, used in these studies, have generally involved betveen-groups analyses, whereas the correlational-based designs used in the prediction studies involved within-group analyses. The l a t t e r analyses are t y p i c a l l y more powerful. Given the trends ln the l i t e r a t u r e review, i t seems that only weak support is found for cognitive v u l n e r a b i l i t y factors. Potential Confounds ln the Cognitive  Vulnerability measures As discussed previously, the l i t e r a t u r e review provides, at best, weak and sometimes inconsistent support for cognitions as v u l n e r a b i l i t y factors. In this section, I argue that the measures used in the l i t e r a t u r e are by nature reactive to a l l e v i a t i o n of depressed mood, and thus are not appropriate measures of cognitive v u l n e r a b i l i t y . Segal (1988) has outlined a number of confounds in the measures used In the l i t e r a t u r e . He questioned the u t i l i t y of the endorsement of negative self-descriptors In the study of v u l n e r a b i l i t y factors as those measures are often mood labels and accordingly, are reactive to the a l l e v i a t i o n of depressed mood, Segal, furthermore, indicated that the SRET was influenced by subjects' response style factors such as s o c i a l d e s i r a b i l i t y . For example, Ferguson, Rule, and Carlson (1983) showed that under the SRET, memory for d e s i r a b i l i t y - r a t e d adjectives was at least as good as for se l f - r a t e d adjectives. S i m i l a r l y , other researchers have raised the p o s s i b i l i t y that depressive memorial biases are attributable 41 to response biases. M i l l e r and Levis (1977) proposed that-depressed individuals may have the correct answers stored in memory but because of an overly cautious response s t y l e , are unwilling to report them to the experimenter. They applied signal detection procedures on depressed and demented patients along with normal controls. This procedure allowed the computation of d' ( d i s c r l m i n a b i l i t y ) and ^ ( d e c i s i o n c r i t e r i o n ) . Depressed subjects did not d i f f e r from the normal controls in d', suggesting that the memory functions of depressed subjects were as e f f i c i e n t as those of the normal controls. However, depresslves were found to use a more conservative response strategy, as evident by the c r i t e r i o n . Dunbar and Lishman (1984) refined this conservative response style as a bias against the reporting of recognized positive words. These Investigators compared hospitalized depressed with normal controls on recognition of words with high (good) or low (bad) hedonic tone. Although the two groups did not d i f f e r in recognition v. performance, depressed subjects appeared to adopt a more stringent c r i t e r i o n for positive words, indicating a bias against recognizing positive words. why do depressed individuals adopt th i s conservative strategy? Johnson and Magaro (1987) proposed that t h i s conservative response bias is a r e f l e c t i o n of the pathology. They argued that depressed individuals are reluctant to display their level of confusion which is inherent in t h e i r depressed state, and so they adopt a conservative style and respond only when they are r e a l l y sure, s i m i l a r l y , zuroff, Colussy, and Wieglo (1983) theorized that depressed subjects who were uncertain whether they selected a negative adjective as s e l f - d e s c r i p t i v e are responding to the hedonic tone of the s t i m u l i , and thus are more l i k e l y than nondepressed subjects to guess that they did. If the memorial biases displayed by depresslves are r e f l e c t i v e of a response s t y l e , and i f that response s t y l e is a result of their depressed state (as suggested by Johnson and Magaro), then memorial biases may be expected to be reversible with the a l l e v i a t i o n of depression. If s e l f - r e p o r t and memory measures used so far in the cognitive v u l n e r a b i l i t y l i t e r a t u r e are by their nature mood reactive, then the next question i s what measures are r e s i l i e n t to mood changes and hence, are more suitable for the investigation of cognitive v u l n e r a b i l i t y factors. As the next chapter shows, some investigators have proposed that the key l i e s in automatic cognitive processes. 43 chapter 4: Automatic Processes as Vulnerability Markers In t h i s chapter, I argue that depressive automatic processes are viable candidates for v u l n e r a b i l i t y markers. F i r s t , automatic and e f f o r t f u l processes are defined. Then application of thi s d i s t i n c t i o n to depression is discussed. Next, a l i t e r a t u r e review of studies on automatic processes In depression is provided. Definitions of Automatic and E f f o r t f u l Processes Some researchers have c l a s s i f i e d cognitive processes as automatic or e f f o r t f u l (Hasher & Zacks, 1979), or strategic (Schneider & S c h i f f r l n , 1977), or conscious (Posner & Snyder, 1975). These researchers have assumed a capacity model of attention (Kahneman, 1975). The capacity model assumes that there is a general l i m i t on the energy available for performing mental operations. That l i m i t or capacity can be allocated f l e x i b l y to d i f f e r e n t stages of processing and to dif f e r e n t processing a c t i v i t i e s . Mental operations d i f f e r in the amount of attention capacity they require. Concurrent mental operations can compete for the amount of capacity so that one task interferes with the other. For example, i t is very d i f f i c u l t to perform mental arithmetic while carrying on a conversation. Various theories d i f f e r somewhat In their d e f i n i t i o n of automatic and e f f o r t f u l processing but common to these theories are the following c r i t e r i a . Automatic processes are those that operate without Intention, without 44 necessarily giving r i s e to awareness, and use no or minimal capacity so as not to interfere with concurrent tasks requiring capacity (Posner & Snyder, 1975). In contrast, e f f o r t f u l operations require considerable capacity (and so interfere with other cognitive a c t i v i t i e s requiring capacity), are i n i t i a t e d intentionally, and show benefits from practice. C l a s s i f i e d d i f f e r e n t l y , e f f o r t f u l processes require attention, while automatic processing is processing without attention (Logan, 1988). Logan (1988) recently proposed that processing resources play no role in the automatic-effortful d i s t i n c t i o n . Rather, the d i s t i n c t i o n l i e s in the acquisi t i o n of knowledge. That i s , novice (or strategy-controlled) performance is limited by a lack of knowledge. Automaticity, Logan continues, r e f l e c t s the build-up of Information in memory. Performance, therefore, is considered automatic when r e t r i e v a l of relevant Information is based, on a single, direct-access step rather than on algorithmic computation. Some of the recent views are that automatic versus e f f o r t f u l processes are part of a continuum rather than discrete processes (e.g., Cohen, Dunbar, & McCelland, 1990). Using t h i s d e f i n i t i o n , self-report and memory tasks used in the cognitive v u l n e r a b i l i t y research f a l l within the e f f o r t f u l end of the continuum since they are both occurring i n t e n t i o n a l l y and with awareness. 45 Automatic Processes as Potential v u l n e r a b i l i t y Markers According to the capacity model, the amount of capacity available can vary depending on a number of factors. Depression is among the variables thought to reduce the t o t a l amount of attentlonal capacity available for processing (Hasher & Zacks, 1979; Kahneman, 1973). Because e f f o r t f u l processes are capacity-demanding, depression can cause a disruption to these processes, in contrast, automatic processes should be unaffected by depression, as these do not require or require minimal capacity. For d i f f e r e n t reasons from above, E l l i s and his colleagues ( E l l i s , Thomas, & Rodrlgez, 1984; E l l i s , Thomas, McFarland, & Lane, 1985) s i m i l a r l y proposed that depression disrupts e f f o r t f u l but not automatic processes. They proposed that some capacity is t i e d up ln thinking about one's depression, reducing the capacity available that can be allocated to a given task. Summarizing, e f f o r t f u l but not automatic tasks may be affected by depressed mood. As discussed previously, processes which are affected by the presence and amelioration of depressive mood may be unsuitable candidates for v u l n e r a b i l i t y markers. Since automatic processes are hypothesized to be unaffected by depressed mood, the p o s s i b i l i t y exists that these processes are more sensitive measures of v u l n e r a b i l i t y factors. As an aside, a d i s t i n c t i o n is made between automatic processes, described above, and Beck's conceptualization of 46 automatic thoughts. What these concepts have i n common Is that they occur without the individual's intention. However, automatic thoughts tend to be repetitive and intrude into consciousness, whereas automatic processes occur outside of one's awareness. Furthermore, automatic thoughts take up processing resources. It is common that depressed patients complain that they cannot focus on other aspects of their l i v e s because of their intrusive, depressive thoughts. In contrast, automatic processing takes up minimal resources (Dalgeish & Watts, 1990). Literature Review on Automatic and E f f o r t f u l  Processes In Depression in this section, I review the l i t e r a t u r e on automatic processes in depression. F i r s t , I review the studies which show that depression affects e f f o r t f u l and automatic tasks d i f f e r e n t i a l l y . A review of general automatic processing studies in depression follows. Then, particular studies on automatic processes as v u l n e r a b i l i t y markers are outlined. Although the previous l i t e r a t u r e review on cognitive v u l n e r a b i l i t y excludes analogue studies, this section does Include such studies because they sometimes use innovative measures that have not yet been t r i e d with a c l i n i c a l l y depressed sample. However, i t should be kept in mind that findings from these studies may not be generallzable to a c l i n i c a l sample. 47 D i f f e r e n t i a l E f f e c t s of Depression on Automatic and E f f o r t f u l Tasks One line of research has found that depressed subjects perform more poorly than normals on effort-demanding but not on automatic tasks. Cohen, Welngartner, Smallberg, Plckar, and Murphy (1982) were among the f i r s t investigators to examine depressives' d i f f e r e n t i a l performance on automatic and more e f f o r t f u l tasks, comparing depressed patients with normal controls, they found that depressed patients were more Impaired on tasks requiring sustained e f f o r t ( r e c a l l i n g a l i s t on nonsense s y l l a b l e s , maintaining their grip on a dynamometer) than on tasks requiring r e l a t i v e l y less e f f o r t (exerting force on the dynamometer). Similarly, Roy-Bryne, Weingarter, Blerer, Thompson, and Post (1986) gave both e f f o r t f u l and automatic tasks to depressed patients and normal controls. Subjects were given a l i s t of word pairs and they were asked to make one of four possible judgments. They were then asked to r e c a l l the l i s t ( e f f o r t f u l task) or, when presented with the word-pair, were asked to indicate which of the four judgments they had made on the word pairs (presumably an automatic task). Additionally, subjects were again presented with the word l i s t (so now this word l i s t i s presented twice) along with a new l i s t . They were then asked to r e c a l l the twice-presented l i s t ( e f f o r t f u l task) and, when presented with the l i s t of word-pairs, to Indicate which of the word l i s t s were 48 presented twice. Depressed patients performed worse than the nondepressed subjects only on the e f f o r t f u l tasks. Two additional studies, s i m i l a r l y , showed that depression disrupts e f f o r t f u l but not automatic processes. Golinkoff and Sweeney (1989) administered frequency of occurrence tests (automatic task), verbal paired associate r e c a l l ( e f f o r t f u l task), and recognition memory tests to depressed inpatients and age- and IQ-matched normal controls. There was no difference in frequency judgments, but depressed subjects recalled and recognized fewer words. Watts and Cooper (1989) found that the effects of Imageabillty (automatic process) of story units were comparable in both depressed and normal subjects. However, depressed subjects showed poorer r e c a l l for units central to the structure.of the story ( e f f o r t f u l process). From a d i f f e r e n t perspective, drugs that ameliorate depression also f a c i l i t a t e performance on e f f o r t f u l but not on automatic tasks. When depressed patients were administered amphetamine, there was a f a c i l i t a t i o n that is sele c t i v e and r e s t r i c t e d to tasks requiring e f f o r t . But th i s f a c i l i t a t i o n was not seen for the automatic tasks (Reus, Silberman, Post, & Weingarter, 1979). Automatic Processing studies In Depression in this section, I show that depresslves automatically process depression-related s t i m u l i . These studies examined automatic processing via the s e l f - r e f e r e n t encoding task, and via perceptual and attentive biases. 49 Self-referent encoding task 3 t u d l e s . Since much of the cognitive v u l n e r a b i l i t y research has focused on the processing of se l f - r e f e r e n t information, i t is appropriate to examine some recent developments in thi s area. Bargh (1982) proposed that s e l f - r e f e r e n t Information is capable of invoking automatic attentional responses. He f i r s t pointed out that automatic processing develops with frequent and r e l a t i v e l y consistent experience with the environmental event (cf. Logan, 1979; S c h l f f r l n & Dumais, 1981; S c h i f f r i n & Schneider, 1977). Since the s e l f is implicated as the organizing force behind s o c i a l Information processing (cf. Markus, 1977), i t follows that people develop automatic attent i o n a l responses to s e l f - r e f e r e n t information. For example, one's own name is one of the rare stimuli capable of breaking through the attenti o n a l barrier and be consciously noticed in the d i c h o t l c l i s t e n i n g task (Moray, 1959). On a dichotlc l i s t e n i n g task, Bargh (1982) found that s e l f - r e f e r e n t information required fewer attentional resources when presented to the attended channel, but more resources when presented to the unattended channel, r e l a t i v e to neutral words. Furthermore, t h i s d i f f e r e n t i a l capacity a l l o c a t i o n occurred despite subjects' lack of awareness of the rejected channel, as indicated by their i n a b i l i t y to select the relevant words ln a subsequent recognition task. MacDonald and Kuiper (1985) attempted to study the issue of automaticity in depression. They asked c l i n i c a l l y depressed and normal subjects to perform a memory load task 50 - to hold d i g i t s in memory - concurrently with the s e l f -referent encoding task. If sel f - r e f e r e n t judgments are r e l a t i v e l y automatic, then (a) the addition of the memory load task would lead to minimal disruption In the performance of the self-referent encoding task, and (b) Increasing the number of d i g i t s on the memory load task, furthermore, would not affect s e l f - r e f e r e n t encoding task performance. MacDonald and Kuiper found no differences In the size of the load effect as a function of group membership (depressed, nondepressed) and adjective content (positive, depression-content). These Investigators argued that these findings support their hypothesis that the s e l f -schema operates automatically. As Bargh and Tota (1988) pointed out, MacDonald and Kuiper*s conclusion is problematic. The schema i s theorized to be content-specific. Thus, the prediction consistent with the hypothesis is the demonstration of automaticity only in the processing of schema-congruent s t i m u l i , that i s , depression-content adjectives for depressed subjects and positive adjectives for nondepressed subjects. The lack of interaction i s not supportive of this prediction. However, this finding cannot be taken as lack of evidence for automaticity of the self-schema, for there were d i f f i c u l t i e s in interpreting the res u l t s . These Investigators measured response latencies to the nearest second. Differences of as l i t t l e as 20 msecs may be r e l i a b l e indicators of processing differences (e.g., Posner, 1978). Thus, their apparent lack 51 of support may be due to the lack of precision of their measures. Si m i l a r l y , Bargh and Tota (1988) attempted to demonstrate automaticity in s e l f - r e f e r e n t i a l judgments. Using a cutoff c r i t e r i o n score of 10 on the Beck Depression Inventory (Beck et a l . , 1961) these investigators asked depressed and nondepressed college students to judge a series of depressed- and nondepressed-content adjectives as to their descriptIveness to the s e l f or to the average person. Some subjects held six d i g i t s in memory concurrent with the judgment tasks, while the remaining subjects had no concurrent memory load while making their judgments. The results showed that the memory load manipulation produced ln a smaller Increase ln depressed subjects' decision latencies for the depression-content adjectives than for the nondepressed-content adjectives. The reverse pattern was found for the nondepressed subjects' judgments. Thus, the results are supportive of the idea that a r e l a t i v e l y automatic process is used to make s e l f - r e f e r e n t i a l judgments. Since the investigators used college students, however, i t is uncertain whether the finding would extend to c l i n i c a l depression. Studies examining perceptual biases. Another r e l a t i v e l y automatic process involves perception. Powell and Hemsley (1984) set out to determine depressives' recognition thresholds for unpleasant and neutral words. Using samples of depressed Inpatients and normal controls, 52 they established a 50% recognition threshold for t a c h i s t o s c o p i c a l l y presented words for each subject. They then compared the r a t i o of unpleasant to neutral words correc t l y recognized. Depressed subjects showed a tendency (p_ < .08) toward a higher recognition r a t i o of unpleasant to neutral words. The investigators argued that their results were supportive of a perceptual bias in c l i n i c a l depression. A related study by MacLeod, Tata, and Mathews (1987) was unsuccessful, however, in documenting perceptual bias in c l i n i c a l depresslves. Using the same stimulus words as Powell and Hemsley (1984), these investigators employed a l e x i c a l decision paradigm with samples of depressed patients and normal controls, on a computer screen, a row of asterisks was displayed. After one second, th i s was replaced by a l e t t e r s t r i n g . Subjects were asked to respond by pressing a key, indicating whether the l e t t e r s t r i n g was a word. In contrast to Powell and Hemsley, these investigators found no interaction between subject groups and valence of st i m u l i . The results are contrary to the hypothesis that perception of mood-congruent information would be f a c i l i t a t e d in depression. Studies examining attentive biases. Gotlib, McLachlan, and Katz (1988) attempted to document vi s u a l attentional biases In dysphoric college students. Three types of word pairs were t a c h i s t o s c o p i c a l l y presented: positive-neutral, depressed-neutral, and positive-depressed. For each t r i a l , one word was printed above the other. After a 730 msec 53 presentation of the word pair, two different colour bars replaced the words. Subjects were asked to report which of the two colour bars they perceived as appearing f i r s t . If subjects were attending to the depressed-content word when the colour bars appeared, the bar that masked that word would be perceived as occurring e a r l i e r , because the perception of the other bar would require a s h i f t In attention, giving r i s e to the perception that the colour bar appeared l a t e r . The r e s u l t s showed that nondepressed subjects showed a greater attentiveness to positive words, as evident by a greater percentage of judgments for bars appearing in the location of the positive words. Dysphoric subjects showed an even-handedness in the i r processing of the d i f f e r e n t word types; they showed roughly equal rates of judgments for both positive and depression-content s t i m u l i . The investigators concluded that this even-handedness pattern f a i l e f l t-0 support- their hypothesis of attentional bias in depression. Conclusions about biases in depression are d i f f i c u l t to draw from th i s study, however, because i t used mildly depressed college students. Other studies using d i f f e r e n t information processing paradigms have produced th i s even-handedness e f f e c t for depression and positive stimuli (e.g., Davis, 1979a), but when that paradigm was applied to c l i n i c a l l y depressed patients, there was a depressive bias for the depression-related stimuli (e.g., Davis, 1979b; 54 Davis & unruh, 1981). i t would be of t h e o r e t i c a l interest-to determine whether the paradigm from the Gotlib et a l . (1988) study is capable of revealing a depressive attentional bias in a sample of c l i n i c a l l y depressed patients. Other researchers have investigated depressives' attentional bias using a version of the Stroop task. The stroop task (stroop, 19 35) has frequently been used by cognitive psychologists to study attentional processes. In the stroop task, the subject's task is to name the colour of the ink in which a word i s printed. In Stroop's (1935) study, subjects took longer to name the colour of the ink when.the base item was an incongruent colour name (e.g 'red' printed in green) than when they were rows of x's. Subsequent research (e.g., Klein, 1964) has found that any word causes some interference, es p e c i a l l y i f the word is associated with an incongruent color (e.g., sky, grass) (Scheibe, Shaver, & Carri e r , 1967). This disruption of the colour-naming performance i s thought to be due to a l l o c a t i o n of attention to more s a l i e n t aspects of the stimulus ( i . e . , the stimulus words). The e f f e c t occurs without any apparent Intention by the subjects, so In this respect the Stroop task taps Into r e l a t i v e l y automatic processing. More recently, researchers have modified the Stroop task to examine cognitive processing in aff e c t i v e disorders. Common to these studies i s the basic task of colour naming of words that are a f f e c t i v e in content. 55 Gotlib and McCann (1984) were among the f i r s t to apply the modified version of the Stroop task to the area of depression. They asked mildly depressed and nondepressed college students to name the colours of depressed-, neutral-, and positive-content words as quickly as possible. The results were supportive of a depressive attentive bias; depressed subjects showed longer response latencies to the depressed-content words than to either the neutral- or the positive-content words, whereas the nondepressed subjects did not show d i f f e r e n t i a l response latencies to the three types of words. This e f f e c t has been replicated in a sample of c l i n i c a l l y depressed inpatients (Gotlib & Cane, 1987). In an interesting application of the Stroop task, Marks, Williams, and Broadbent (1986) demonstrated that patients automatically process stimuli related to their psychopathology. They studied the Stroop performance of a sample of patients who had recently attempted suicide by drug overdose. They found a greater disruption in naming words that were more s p e c i f i c a l l y related to their psychopathology (e.g., overdose, drug) than in more general negative emotional words (e.g., immature, helpless). Furthermore, the extent of t h i s disruption was correlated with levels of current depressed mood, rather than current anxiety. 56 V u l n e r a b i l i t y s t u d i e s Examining Automatic Processes A review of studies addressing depressive automatic processing as v u l n e r a b i l i t y factors shows that this is a r e l a t i v e l y unexplored area. Two studies are relevant here. Williams and Nulty (1986) asked whether emotional stroop disruption r e f l e c t s current mood l e v e l or a more permanent t r a i t mood l e v e l . They tested college students with the Beck Depression inventory (Beck et a l . , 1961) on two occasions, 1 year apart. The subjects were given a Stroop task using emotional words. Three groups of subjects are of inte r e s t : stable depressed (those who were depressed at both t e s t i n g sessions), stable nondepressed (those who were nondepressed at both sessions), and unstable depressed (those who tested depressed at the f i r s t session, but tested nondepressed at the second session). As expected, the greatest disruption was found for the stable depressed subjects, while the smallest disruption was observed for the stable nondepressed. For the unstable depressed group, the extent of the disruption in colour naming was predictable on the basis of the i r I n i t i a l mood l e v e l , rather than their lower l e v e l at time of testing. Again, a caveat is extended in t h i s study's a p p l i c a b i l i t y to c l i n i c a l depression since i t employed college students. Using a c l i n i c a l sample, Gotllb and Cane (1987) also examined whether depressive vis u a l attentional bias is a stable aspect of cognitive processing in depressed in d i v i d u a l s . Depresssed psychiatric patients and 57 nondepressed controls were administered the Stroop task twice. in the f i r s t administration, the hospitalized depressed patients took longer to name the colours of the depressed-content than for the nondepressed-content words, whereas the response latencies of nondepressed subjects did not d i f f e r for the three types of words. Thus, the depressive attentional bias effect was replicated. The second administration was obtained upon symptomatic recovery of the depressed patients. At that session, the recovered depressives' performance resembled that of the nondepressed controls, indicating that the depressive attentive bias had shif t e d with the a l l e v i a t i o n of depressed mood. It appears, using t h i s task, that attentional bias is not a stable aspect of depressed individuals. Summarizing, depression appears to a f f e c t automatic and e f f o r t f u l cognitive processes d i f f e r e n t i a l l y . There is evidence that depressives automatically process depression-related s t i m u l i . A review of the l i t e r a t u r e examining automatic processes as v u l n e r a b i l i t y markers suggests that t h i s Is a r e l a t i v e l y unexplored area. Out of the two studies, one showed negative r e s u l t s . However, ln a r e l a t i v e l y unexplored area, one negative finding should not mean sudden death to that area. With th i s in mind, I now turn to exploring automatic processes as candidates for v u l n e r a b i l i t y factors. 58 Chapter 5: Statement of Research Problem and General Method I propose that automatic processing of depression-related stimuli i s a sensitive measure of v u l n e r a b i l i t y markers in depression. This idea was examined in the following manner. Three groups of subjects were used: currently depressed, remitted depressed, and nondepressed subjects. These subjects were given tasks which involve processing that is either e f f o r t f u l or automatic. Three months after t h i s experimental session, they were asked to f i l l out a questionnaire which assessed depressive symptoms. Four main hypotheses were examined: (a) depressed individuals would show depressive biases In the automatic tasks; (b) remitted depressed individuals' pattern of performance on the automatic tasks would resemble that of the currently depressed individuals; (c) remitted depressed indi v i d u a l s ' pattern of performance on the e f f o r t f u l tasks would resemble that of the nondepressed individuals; and (d) measures of depressive automatic processes would be predictive of future depressive symptoms. The remainder of this chapter provides the conceptual background for the tasks used. The intent of this is to demonstrate the r e l a t i v e l y automatic and e f f o r t f u l natures of the tasks, using the assumption that automatic versus e f f o r t f u l processes f a l l on a continuum. More details of the tasks are provided in the subsequent chapters. 59 Conceptual Description of Tasks Used Three r e l a t i v e l y automatic tasks were used. These were: dichotlc l i s t e n i n g , probe detection, and Implicit memory tasks. In addition to the three automatic tasks, s e l f - r e p o r t questionnaires were administered. These were: Automatic Thoughts Questionnaire, Hopelessness Scale, and the Dysfunctional Attitude Scale. These were chosen as they were developed under Beck and his colleagues' cognitive framework, and these measures have t r a d i t i o n a l l y been used ln the cognitive v u l n e r a b i l i t y l i t e r a t u r e . In the dichotlc l i s t e n i n g task (Cherry, 1 9 7 3 ) , subjects are asked to repeat or shadow messages played to one ear, while ignoring simultaneously presented messages to the other ear. Despite the Instructions to ignore the unattended message, there is strong evidence that considerable processing of the unattended information is taking place. For example, when a word in the unattended ear is a synonym of a simultaneously presented word In the shadowed ear, shadowing slows down (Lewis, 1 9 7 0 ; Trelsman, Squire, & Green, 1 9 7 4 ) . In a study by McKay ( 1 9 7 3 ) , subjects were l i k e l y to interpret the sentence 'she sat by the bank' in quite d i f f e r e n t ways when the words 'river' or 'money' occurred in the unattended channel. There is also good evidence that the processing of the unattended message can proceed unconsciously. For example, subjects in Bargh's (1982) study appeared to be unaware of the content of the unattended channel, ln that they were unable to recognize 60 the relevant words when shown to them la t e r , since processing of the unattended message proceeds without subjects' intention and awareness, this type of processing is considered to be r e l a t i v e l y automatic. Another seemingly automatic process is the involuntary a l l o c a t i o n of attention to salient aspects of the environment. For example, one may be focused on one conversation at a party only to be Interrupted upon hearing one's name spoken in the context of another conversation. This i s an i l l u s t r a t i o n of the cocktail party phenomenon. Williams, Watts, MacLeod, and Mathews (1988) provided some c l i n i c a l examples of the c o c k t a i l party phenomenon. M. M. had a phobia of birds. To avoid any potential encounters with birds, she developed extreme s e n s i t i v i t y to bird-type stimuli in her environment. She would avoid dark, flapping objects several meters away, lest the object turn out to be a b i r d . M. M. would notice l i v e and dead birds far more frequently in her environment than would her friends and family. Williams et a l . saw this s e n s i t i v i t y to fear-related stimuli as an example of attention bias s p e c i f i c to t h i s p a r t i c u l a r psychopathology. The s t r i k i n g feature of t h i s attentional bias is i t s seemingly involuntary nature. It is very l i k e l y that M. M. cannot ignore b i r d - l i k e aspects of her environment, even i f she wanted to. This involuntary nature of attentional bias is stated by Williams et a l . ( i y 8 8 ) : We assume that attentional bias can be said to have 61 occurred when there is a discrete change in the dir e c t i o n in which a person's attention i s focused so that he/she becomes aware of a part or aspect of h i s / her environment. We also assume that such a change (a) may take place in any sense modality; (b) is perceived as being passive or Involuntary but can operate v o l u n t a r i l y and (c) is normally perceived to be contingent upon a discrete change (onset or offset) in the 'internal' or 'external* environment of the person, (p. 54, emphasis mine). Attentional biases, then, appear to be the result of r e l a t i v e l y automatic processes. This involuntary capturing of attention by s a l i e n t aspects of the environment has also been experimentally investigated by the v i s u a l probe detection paradigm (MacLeod, Mathews, & Tata, 1986). In this paradigm, pairs of words are b r i e f l y presented on top and bottom parts of a computer screen. Subjects are asked to read the top word aloud. On some t r i a l s , a probe (a small dot) is presented in either of the locations in which the words appeared, and when this occurs, subjects are to press a button as quickly as p o s s i b l e . Consider the case where one of the two words presented contained self-relevant information. Subjects* attention would be drawn to the area where that word appeared. If subjects' attention were drawn to an area where a probe presentation followed, they would be quicker to detect the probe. On the other hand, i f s u b j e c t s ' a t t e n t i o n were drawn elsewhere from where the probe appeared, they would be slower to d e t e c t i t . Yet another task t h a t does not depend on awareness i s the I m p l i c i t memory task . I m p l i c i t memory Is s a i d to occur when memory f o r a r e c e n t event or experience a f f e c t s performance on a subsequent task, i n the absence of s u b j e c t s ' conscious or d e l i b e r a t e attempt to r e c a l l t h a t event or experience. T h i s phenomenon was s t r i k i n g l y i l l u s t r a t e d by the n i n e t e e n t h century n e u r o l o g i s t Claparede (as r e p o r t e d l n E l l e n b e r g e r , 1970). In the course of h i s rounds, Dr. Claparede, while h o l d i n g a pin In h i s hand, shook hands with an amnesic p a t i e n t . Later that day, the amnesic p a t i e n t had no r e c o l l e c t i o n of having met Dr. Claparede, but had an i n e x p l i c a b l e r e l u c t a n c e to shake hands with him. In a s i m i l a r f a s h i o n , amnesic p a t i e n t s , a f t e r being asked questions t h a t disambiguated homophones i n one d i r e c t i o n (e.g., "Name a musical instrument t h a t employs a r e e d " ) , were more l i k e l y to s p e l l homophones c o n s i s t e n t with t h a t meaning, although they were unable to r e c a l l or r e c o g n i z e the words they used as ones presented p r e v i o u s l y (Jacoby & Witherspoon, 1982). I m p l i c i t memory i s c o n t r a s t e d with e x p l i c i t memory, which i s the a b i l i t y to r e c a l l i n f o r m a t i o n i n a d e l i b e r a t e or i n t e n t i o n a l manner (e.g., the r e c a l l component of the SRET). Mandler (1980) proposed t h a t i m p l i c i t memory r e s u l t s from the a c t i v a t i o n of a mental r e p r e s e n t a t i o n , or schema, t h a t strengthens the I n t e r n a l s t r u c t u r e of that 6 3 representation (integration), thus making i t more accessible but not necessarily more retrievable. E x p l i c i t memory depends on the extent to which the activated schema is related to other information at the time of encoding (elaboration), thereby ensuring that associated representations can be activated to serve as r e t r i e v a l cues. Mandler and his colleagues (Graf & Mandler, 1984; Mandler, Graf, & Kraft, 1986) further proposed that activation/integration is regarded as being r e l a t i v e l y automatic, whereas elaborative processing is s t r a t e g i c , subject controlled, and conscious. 64 Chapter 6: Method The rest o£ the thesis is organized in the following manner. The subjects section is presented f i r s t . It consists of a description of the measures used in subject c l a s s i f i c a t i o n , a discussion of the subject selection c r i t e r i a , and a description of the subject c h a r a c t e r i s t i c s . Next, the overall procedure section provides an overview of how the study was conducted. The present chapter is followed by separate chapters on the dichotlc l i s t e n i n g , probe detection, and im p l i c i t memory tasks, and on the s e l f -report questionnaires. Each of these chapters contains a descr i p t i o n of the task and the main dependent measures, the general procedure, a l i s t of hypotheses that were examined, the r e s u l t s , and a brief summary. The results focus on the between-groups comparisons. Next, the follow-up data are described. F i n a l l y , the results of a l l the tasks are compared and discussed. Subjects Measures D S M - I I I - R diagnoses. The Diagnostic and S t a t i s t i c a l Manual for Mental Disorders (3rd ed. - Revised) ( D S M - I I I - R ; American Psychiatric Association, 1987) was used for diagnosis of Major Depressive Episode and Dysthymia. The D S M was chosen since i t represents the most prevalent diagnostic system in Canada (Junek, 1983). The D S M has also additional merits. It Is intended to be an atheoretical diagnostic system. Furthermore, D S M diagnoses r e f l e c t 65 c l i n i c a l consensus on what symptoms c o n s t i t u t e the various disorders. To date, l i t t l e published research is available for the revised version of the DSM-III. However, r e l i a b i l i t y studies are available for DSM-III. In two f i e l d t r i a l s , r e l i a b i l i t y s t a t i s t i c s for Major Depressive Disorders were kappas of .68 and .80 (American Psychiatric Association, 1980), suggesting adequate agreement among raters. Schedule for Affective Disorders and Schizophrenia. The Schedule for Affective Disorders and Schizophrenia (SADS; Endicott & Spitzer, 1978) Is a structured Interview designed to provide diagnostic decisions on a wide v a r i e t y of psychiatric disorders. It was developed to provide research Investigators with a standard c l i n i c a l procedure in order to increase r e l i a b i l i t y of diagnostic and descriptive evaluations of subjects. Although the o r i g i n a l intent of the SADS was to provide diagnoses according to Research Diagnostic C r i t e r i a , i t can be adapted to provide DSM-III-R diagnoses. Three versions of the SADS are available: the regular version, the life t i m e version, and the change version. This thesis used a modified version of the 1ifetime-SADS - - the version that was used is based on only those items that pertain to the assessment of lifetime incidence of depression, thought disorder, and mania (see Appendix A). Psychometric properties of the SADS are considered to be good. In par t i c u l a r , the SADS has good r e l i a b i l i t y . 66 Based on 150 interviews, Endicott and Spitzer (1978) reported inter-rater r e l i a b i l i t y c o e f f i c i e n t s of .95 or more, with respect to r e l i a b i l i t y of depression diagnoses made through SADS interviews, Spitzer, Endicott, and Robins (1978) reported kappa coe f f i c i e n t s of .90 and .81 for diagnoses of major depressive disorder and minor depressive disorder, respectively. In terms of concurrent v a l i d i t y , the SADS correlates moderately with other scales of depression. It correlates .42 with the depression scale of the Katz Adjustment Scale (Katz & Lyerly, 1963), and .68 with the depression scale.of the Symptom Checklist (Derogatls, Lipman, & Covi, 1973). Hamilton Rating Scale for Depression. The Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960; 1967; see Appendix B) is h i s t o r i c a l l y the most commonly used interview measure of depression. The HRSD provides an index of severity of depression for Individuals already diagnosed as depressed. It Is not Intended as a diagnostic instrument. Several versions are available. The o r i g i n a l version contains 21 items, 17 of which are scored. The remaining four items (diurnal variation, depersonalization, paranoia, obsessive-compulsiveness) are not scored since they were found either to be unrelated to the severity of depression or appeared too infrequently. The 24-ltem version includes four cognitive items, assessing hopelessness, helplessness, and worthlessnes3. However, most researchers do not score 67 t he se cognitive items. This study used the 24-item version of the scale, but r e l i e d on only the 17 scorable items. For the 17 scorable items, the t o t a l range of scores is from 0 to 52 , where higher scores are suggestive of greater severity of depression. Guidelines for I n t e r p r e t i n g HRSD scores are provided by Shaw, v a l l i s , and McCabe ( 1 9 8 5 ) . HRSD scores of six or below are considered to r e f l e c t n o n d e p r e s s e d functioning, scores between 7 and 17 r e f l e c t mild levels of depression, scores between 18 and 24 r e f l e c t moderate levels of depression, and scores greater than 25 r e f l e c t severe levels of depression. The HRSD i s t y p i c a l l y scored after a c l i n i c a l Interview. To increase r e l i a b i l i t y , a semi-structured interview (see Appendix C) was used based on interview probes provided by Klerman, Weissman, Rounsaville, and Chevron (1984) and using the scoring guidelines provided by Beckham and Leber ( 1 9 8 5 ) . Inter-rater r e l i a b i l i t y data on the HRSD are good. In a survey of research reports oh the HRSD from 1967 to 1979, Hedlund and Vieweg (1979) cited nine studies that reported inter-rater r e l i a b i l i t y c o e f f i c i e n t s of .84 or above. Although Hamilton recommends that the HRSD is most e f f e c t i v e l y used by experienced c l i n i c i a n s (Hamilton, 1 9 8 6 ) , the HRSD can be used by novice raters with minimal t r a i n i n g . After 5 hours of t r a i n i n g , the three undergraduates used ln this study reached inter-rater r e l i a b i l i t i e s of . 7 6 . Furthermore, each of these three 68 undergraduates' ratings correlated at least .82 with the mean ratings for four expert judges. The HRSD has demonstrated moderate associations with other measures of depression. Based on a survey of a wide variety of studies, Hedlund and Vieweg (1979) reported median correlations between the HRSD and Beck Depression Inventory of . 5 8 , the Zung Self-Rating Depression Scale of . 4 5 , and the Minnesota Multiphasic Personality Inventory -Depression scale of . 4 4 . The HRSD is sensitive to change in the severity of depression, as evidenced by i t s frequent use in drug outcome studies. Beck Depression Inventory. The Beck Depression Inventory (BDI; Beck et a l . , 1 9 6 1 ; see Appendix D) is the most frequently used self-report Inventory to assess severity of depression. The BDI provides a comprehensive survey of depression symptomatology without r e f l e c t i n g any particular theory of etiology of depression. It asks the respondent to describe his or her current level of depression. The scale contains 21 items where each item consists of four self-evaluative statements of increasing severity. Each Item is scored from 0 to 3 , y i e l d i n g a f u l l scale score ranging from 0 to 6 3 . Generally recommended guidelines for interpreting BDI scores are the following: 0 to 9 r e f l e c t nondepressed levels of functioning, 10 to 15 r e f l e c t mild levels of depression, 16 to 23 r e f l e c t moderate levels of depression, and 24 to 63 r e f l e c t severe levels of depression (Shaw, V a l l i s , & M c c a b e , 1 9 8 5 ) . 69 Much research Is available on the BDI (cf. Beck, Steer, & Garbin, 1988). The results suggest that the BDI has satisfactory internal consistency. Based on studies done between 1961-1986, a meta-analysis of the BDI's internal consistency estimates yielded a mean c o e f f i c i e n t alpha of .86 for psychiatric patients and .81 for nonpsychiatric patients (Beck et a l . , 1988). Furthermore, Oliver and Burkhan (1979) reported a test-retest r e l i a b i l i t y c o e f f i c i e n t of .78 over a period of three weeks. The BDI also shows a reasonable degree of concurrent v a l i d i t y . It has moderate to good correlations ranging from .56 to .80 with the Hamilton Rating scale for Depression, the Minnesota Multiphasic Personality Inventory - Depression Scale, the Zung Self-Rating Scale, and the Multiple Affect Adjective Checklist (Bloom & Brady, 1968; Burkhar, Gynther, & Fromuth, 1980; Nussbaum, Wittig, Hanlon, & Kurland, 1963; Schwab, Bialow, & Holzer, 1967; Williams, Barlow, & Agras, 1972; Zung, 1969). In addition, the BDI correlates .62 to .77 with c l i n i c i a n s ' global ratings of depression (Bumberry, Oliver, & Mcclure, 1978; Metcalfe & Goldman, 1965; Nussbaum et a l . , 1963; Salking, 1969). F i n a l l y , the BDI is r e f l e c t i v e of symptom changes, as indicated by i t s frequent use in outcome studies. 70 Subject C l a s s i f i c a t i o n C r i t e r i a This section describes the c r i t e r i a used for subject selection. Three groups of subjects were used. They were: a currently depressed group (CDG; n = 20), a remitted depressed group (RDG; n = 20), and a group of nondepresssed community controls (NDG; n = 20). A l l subjects had to be between the ages of 18 to 65, have a minimum of eighth grade education or possess s u f f i c i e n t reading a b i l i t y to complete the self-report scales unassisted, and could not have a hearing impairment. In addition, subjects were excluded i f they met the Diagnostic and S t a t i s t i c a l Manual for Mental Disorders (3rd ed. - Revised) (DSM-III-R; American Psychiatric Association, 1987) diagnoses for bipolar Il l n e s s , substance use disorder, organic brain syndrome, mental retardation, or schizophrenia and other psychotic disorders. Subjects were c l a s s i f i e d into the d i f f e r e n t groups by the following c r i t e r i a . Subjects in the currently depressed group met the DSM-III-R c r i t e r i a for Major Depressive Episode or Dysthymia. These c r i t e r i a are reproduced in Appendix E. In addition, assurances were made that these subjects were in a depressed state at the time of testing, as Indicated by Beck Depression Inventory (BDI; Beck et a l . , 1961) scores of 15 or more and 24-item version Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960, 1967, 1986) scores of 17 or more. These subjects could not be undergoing cognitive therapy since cognitive therapy 71 e x p l i c i t l y attempts to a l t e r the depressive schema (Beck et-a l . , 1979). Subjects undergoing electroconvulsive therapy were also excluded, because electroconvulsive therapy has been suggested to a l t e r cognitive functioning, at least on a short term basis (Squire, Slater, & M i l l e r , 1981). Subjects in the remitted depressed group had at least one previous episode of major depression (as assessed by SADS - lifetime prevalence, see Appendix A), but were not at the time of testing, undergoing a depressive episode, as assessed by BDI scores of 14 or less and HRSD scores of 16 or less. As well, any subjects who had received electroconvulsive treatments or Cognitive Therapy ln the past were excluded. The two c l i n i c a l samples were recruited from the inpatient and outpatient wards of the University Hospital -University of B r i t i s h Columbia s i t e . The s u i t a b i l i t y of the patient samples were i n i t i a l l y screened by consultation with the nursing s t a f f and the hospital charts. Subjects in the nondepressed group had no history of major depression and, at the time of testing, were not depressed as defined by BDI scores of 14 or less and HRSD scores of 16 or less. The community control sample was a recruited through advertisements placed on b u l l e t i n boards at three community centres, two acquatic centres, a dance school, and three community l i b r a r i e s . 72 Subject C h a r a c t e r i s t i c s A t o t a l of 72 s u b j e c t s were I n i t i a l l y r e c r u i t e d . F i v e of the nondepressed community c o n t r o l s were excluded, when i t was found during the experimental s e s s i o n that they had a dlagnosable previous episode of major de p r e s s i o n , as given by the SADS-Llfetlme Interview. Two of the p a t i e n t s u b j e c t s were excluded when t h e i r d e p r e s s i o n measures gave an I n c o n s i s t e n t p i c t u r e : one I n d i v i d u a l who was r a t e d by the h o s p i t a l p s y c h i a t r i s t as depressed produced a Hamilton score of l e s s than 17; and another i n d i v i d u a l had a Hamilton score of g r e a t e r than 17, I n d i c a t i n g the presence of a de p r e s s i v e mood, but produced an I n c o n s i s t e n t BDI score of l e s s than 15. Another three s u b j e c t s were dropped because they c o u l d not s u c c e s s f u l l y complete the experimental t a s k s : two s u b j e c t s could not perform the d i c h o t i c l i s t e n i n g task, whereas one had a v i s i o n problem and could not read words d i s p l a y e d on the computer sc r e e n . The f i n a l sample comprised 60 i n d i v i d u a l s with 20 s u b j e c t s In each group. The c u r r e n t l y depressed group c o n s i s t e d of 13 I n p a t i e n t s and 7 o u t p a t i e n t s , while the rem i t t e d depressed group c o n s i s t e d of 3 i n p a t i e n t s and 17 o u t p a t i e n t s . A l l s u b j e c t s i n the c u r r e n t l y depressed group were, a t the time of t e s t i n g , undergoing pharmacotherapy, and a l i s t of t h e i r medications Is provided i n Appendix F. E i g h t of the 20 remitted depressed s u b j e c t s were, a t the time of t e s t i n g , on a n t i d e p r e s s a n t s , and a l i s t , of t h e i r medications i s provided i n Appendix F. Nineteen s u b j e c t s i n 73 the c u r r e n t l y depressed group met DSM-III-R c r i t e r i a for Major Depressive Episode, whereas one met DSM-III-R c r i t e r i a for Dysthymia. A l l subjects in the remitted depressed group has had at least one previous episode that met DSM-III-R c r i t e r i a for Major Depressive Episode. The patients were asked to estimate the number of previous episodes of depression. The currently depressed subjects estimated an average of 2 . 5 6 (SD = 2 . 7 9 ) episodes of depression prior to the i r current depressive episode. They ranged from having no episodes of depression other than their current depressive episode, to 12 episodes of depression prior to their current depressive episode. They estimated, at the time of tes t i n g , their average duration of their present depressive episode as 2 7 . 2 7 months (SD = 3 8 . 9 7 ) , with a range from one month to 132 months. The remitted depressed subjects estimated their average number of previous episodes of depression as 3 . 0 6 (SD = 1 . 6 2 ) with a range from one prior episode to six prior episodes. For this group, the average length of remission from the last episode was estimated as 4 2 . 4 9 months (SD = 7 4 . 8 3 ) with a range from one month to 216 months. Demographic and s o c i a l factors. The demographic ch a r a c t e r i s t i c s of the subjects are summarized In Table 1 . The CDG consisted of 13 women and 7 men, the RDG consisted of 16 women and 4 men, while the NDG consisted of 13 women and 7 men. Their ages ranged from 23 to 65 years with an overall average of 3 9 . 9 (SD = 1 1 . 2 8 ) years. i 74 "Table 1 Demographic characteristics of Subject Groups CDG RDG NDG n Age M SD 40.35 (8.63) 47 .65 (11.01) 31.70 (8.07) <.001* Sex r a t i o : (female/male) 13/7 16/4 13/7 N.S.+ Marital status: Marrled/Separated, divorced, or widowed/single 10/6/4 14/3/3 11/3/6 N.S.+ No. of children M SD 1.30 ' (1.26) 1.65 (1.10) .75 (1.10) N.S. * No. of years of M education SD 14.30 (3.13) 14.65 (3.56) 15.75 (1.71) N.S.* Employment status: employed/not employed due to d i s a b i l i t y / umemployed 6/10/4 11/2/7 18/1/1 <.05 + Socioeconomic status M 141.25 SD (93.34) 162.14 (111.83) 190.82 (114.29) N.S.* Note. CDG = Currently depressed group. RDG = Remitted depressed group. NDG = Nondepressed group. + Based on chi-square s t a t i s t i c . * Based on analysis of variance. Socioeconomic status estimates based on Blishen & McRoberts (1975). 75 Chi square tests and analyses of variance were conducted on the measures of subjects c h a r a c t e r i s t i c s . The results show that the three groups did not d i f f e r • s i g n i f i c a n t l y i n p r o p o r t i o n of males and females ( %i 2t2,N = 60) = 1.43, p_ > .05), marital status ( *f3~(6, N = 60) = 6.18, p_ > ,05), number of children (F(2,57) = 3.07, p_ > .05), number of years of education (F(2,57) = 1.35, p_ > .05), and socioeconomic status (F(2,57) = .90, p_ > .42), but did d i f f e r s i g n i f i c a n t l y with respect to employment status (^t2" (4,N = 60) = 22.10, p_ < .001). The l a t t e r r e s u l t r e f l e c t s patients' status: the unemployability of the two patient groups is due to the disabling effects of the depression. In addition, the three groups tended to d i f f e r s i g n i f i c a n t l y in their age (F(2,57) = 14.66, p_ < .001, MSe = 86.97), with Tukey comparisons Indicating that subjects in the RDG are s i g n i f i c a n t l y older than the subjects in the other two groups (RDG vs. CDG: g(3,57) = 3.49, p. < .05; RDG vs. NDG: q(3, 57) = 7,63, p_ < .01), and the subjects in the currently depressed group being s i g n i f i c a n t l y older than the subjects in the nondepressed group, g(3,57) = 4.14, p_ < .01. The importance of th i s age difference between groups w i l l be s p e c i f i c a l l y addressed in the results section. 76 Depression data. The BDI and the HRSD were used as measures of severity of depression. The data are summarized in Table 2, An one-way analysis of variance (F(2,57) = 96.44, p_< .001, MSe = 48.11) conducted across groups on the BDI scores confirmed that the groups were discriminable on the basis of their BDI scores. Based on Tukey comparisons, the CDG had s i g n i f i c a n t l y higher BDI scores than the RDG (g(3,57) = 16.12, p_ < .01) and NDG (g(3,57 ) = 18 . 64, p_ < .01). Furthermore, the RDG and the NDG were not s i g n i f i c a n t l y d i f f e r e n t with respect to their BDI scores (g(3,57) = 2.52, p_ > .05) . With respect to the HRSD scores, i n i t i a l analyses were conducted to ensure adequate r e l i a b i l i t y of the ratings. Ten of the 60 interviews were taped and rated Independently by an experienced c l i n i c a l psychologist and depression researcher. Kent and Foster (1970) suggest that r e l i a b i l i t i e s be computed on the units used for s t a t i s t i c a l analysis. Thus, a Pearson-product moment correlation c o e f f i c i e n t was computed on the overall ratings from the 10 interviews. The obtained r of .99 (p_ < .001) shows a high le v e l of agreement among the raters. To check for systematic bias of one rater consistently scoring higher than the other rater, Hartmann (1977) recommends computing a t-test on the mean ratings for each observer. A nonsignificant t-test (t(8) = .06, p_> .05) suggests an absence of this type of bias. Table 2 Depression Measures at Time of Testing CDG RDG NDG Measures BDI M SD 30.80 (11.01) 5.80 (4.11) 1,90 (2.49) HRSD M SD 28.53 (5.83) 5.67 (5.09) 2.10 (2.17) Note. CDG = Currently depressed group. RDG = Remitted depressed group. NDG = Nondepressed group. BDI = Beck Depression Inventory. HRSD = Hamilton Rating Scale for Depression. 78 Given s u f f i c i e n t r e l i a b i l i t y of the HRSD scores, a between-groups analysis of variance was then computed and was s i g n i f i c a n t , F ( 2 , 5 7 ) = 170 . 5 8 , p_ < .0001, MSe = 2 2 . 4 2 . Using Tukey comparisons, the CDG had s i g n i f i c a n t higher HRSD scores than both the RDG (g(3,57) = 21. 3 9 , p_ < .01) and the NDG (g( 3, 57 ) = 21. 42, p_ < . 0 1 ) . Additionally, the RDG did not have s i g n i f i c a n t l y higher HRSD scores than the NDG (g(3, 57) = 3.07, p_ > .05) . In summary, the groups of subjects had the expected pattern of depression scores. The CDG c l e a r l y had higher depression scores than the other two groups, whereas the RDG and NDG were roughly equated for depression scores. Overall Procedure The study was conducted in two phases. The f i r s t phase was conducted in a laboratory located in the Psychology Building. A l l subjects were tested i n d i v i d u a l l y . A l l subjects gave informed consent to a study of "Thoughts and Emotions" (see Appendix A). Subjects were f i r s t asked to participate In the Implicit memory task. This task was presented f i r s t so that the words from the subsequent tasks would not serve as potential primes. The dichotlc l i s t e n i n g and vi s u a l probe tasks followed. The order of administering these two tasks was determined randomly. Subjects then participated ln an interview (see Appendix H), which involved the c o l l e c t i n g the following information: demographic information, history of thought disorder and mania, Hamilton Rating Scale scores, history of depression 7 9 (for nondepressed community c o n t r o l s o n l y ) , and number o£ previous episodes of depression (for the two depressed groups only). F i n a l l y , subjects were asked to complete the Beck Depression Inventory, the Dysfunctional Attitude Scale, the Hopelessness Scale, and the Automatic Thoughts Questionnaire. The entire procedure lasted approximately 1 1/2 hours. The second phase of the study involved the c o l l e c t i o n of follow-up of depression status, approximately 3 months after the I n i t i a l session. This was done by mailing the Beck Depression Inventory to subjects. 80 c h a p t e r 7 : Dichotic l i s t e n i n g task This task was designed to investigate whether the involuntary processing of information related to depression d i f f e r s between depressed and nondepressed in d i v i d u a l s . This paradigm was adapted from Bargh (1982) and Mathews and MacLeod ( 1 9 8 6 ) . Subjects were asked to shadow neutral stories in a dichotic l i s t e n i n g task while simultaneously being exposed to depression-related or positive words in the unattended channel. It was assumed that the presence of the unattended words would a t t r a c t processing resources, causing a disruption of ongoing tasks. This disruption was measured by requiring subjects to, concurrently with the dichotic l i s t e n i n g task, detect a v i s u a l probe, the word "PRESS", presented intermittently on a computer screen. The probe detection latencies, then, were considered as an index of spare processing resources after the requirements of the other tasks had been met. It was hypothesized that the presence of a depressive schema would f a c i l i t a t e processing of depression-related information. Thus, the presentation of depression-related words would be less disruptive to schematic depressed Individuals than nondepressed nonschematlc individuals. Method M a t e r i a l s S t o r i e s . Four s t o r i e s were co n s t r u c t e d and these are presented In Table 1 o£ Appendix I. These n a r r a t i v e s t o r i e s were c o n s t r u c t e d to be n e u t r a l i n content, so that they d i d not arouse any a f f e c t that may have p o t e n t i a l l y a l t e r e d the p r o c e s s i n g of the a f f e c t - l a d e n m a t e r i a l i n the unattended channel. Each s t o r y was recorded by a male reader, l a s t e d approximately 25 seconds, and contained 60-61 words. Unattended words. Two s e t s of words were presented i n the unattended channel: 15 d e p r e s s i o n - r e l a t e d and 15 p o s i t i v e a d j e c t i v e s . These are presented i n Table 3. The words were read by a female reader at the r a t e of one word per second. These words were s e l e c t e d on the bases of t h e i r high or low r a t i n g s of d e s c r i p t i v e n e s s of d e p r e s s i o n , as provided by Myers (1984). On a range from 1 to 9 (high scores i n d i c a t e r e l a t e d n e s s to d e p r e s s i o n ) , the averaged r a t i n g s f o r the d e p r e s s i o n - r e l a t e d words was 8.11, whereas the averaged r a t i n g s f o r the p o s i t i v e - c o n t e n t words was 1.58. As w e l l , the two s e t s of words were roughly equated for word frequency, which were taken from C a r r o l l , Davis, and Richman (1971). The d i s t r a c t o r words used i n the r e c o g n i t i o n task were matched with the t a r g e t words with r e s p e c t to word frequency and r a t i n g s of d e p r e s s i o n . Since the analyses i n v o l v e d the c o n f i r m a t i o n that the t a r g e t and the d i s t r a c t o r s words were Indeed matched, the p r o p e r t i e s of Table 3 stimulus words f o r D i c h o t l c L i s t e n i n g Task Depression- Freq Dep target abandoned 69 7. ,81 apathetic 2 7. .75 beaten 71 8, ,19 bleak 19 7. ,85 despa i r ing 8 8. ,27 destitute 2 7. ,89 downcast 6 8. ,77 gloomy 29 8. ,04 gr ieved 12 8. ,00 miserable 53 8, ,39 r e g r e t f u l 2 8, ,00 remorseful 2 8. .12 s u i c i d a l 2 7, .85 t e a r f u l 6 8, .62 weary 104 8, .15 M SD 25.80 (32.6) 8.11 ( .30) Depression- Freq Dep di s t r a c t o r a f f l i c t e d 17 7, .75 anguished 4 8, .46 burdened 2 8, .31 def i c i e n t 4 8, .04 deserted 52 8, .00 devasted 10 8, .08 d u l l 54 8, .00 f o r l o r n 3 8, .27 gloomy 29 8, .04 g u i l t y 44 7, .62 melancholy 28 7, .69 shattered 42 8, .12 sorry 285 7, .92 worthless 20 8, .00 wretched 21 7, .92 41.00 8, .01 (69.8) (.23) Positive-target P o s i t i v e - d i s t r a c t o r achieving 15 2. 08 carefree 17 1. 46 amusing 34 1. 50 contented 39 1. 73 bold 87 1. 65 eager 159 1. 54 bubbly 6 1. 42 encouraged 79 1. 27 carefree 17 1. 46 entertaining 20 1. 39 capable 86 1. 46 l i v e l y 129 1. 39 cheerful 87 1. 56 merry 97 1. 31 delighted 91 1. 15 optimistic 15 1. 69 dynamic 28 1. 54 outgoing 6 1. 46 fortunate 52 1. 65 refreshed 9 1. 69 giggly 11 1. 58 relaxed 42 2. 58 j o y f u l 23 1. 46 robust 8 1. 42 playful 29 1. 46 sociable 3 1. 89 respected 37 1. 65 successful 236 1. 92 s a t i s f i e d 133 2. 12 wittv 4 1. 77 M 49.07 1. 58 57.53 1. 63 SD (38.21) (.24) (69.70)(.33) Note. Freq = word frequency. Ratings taken from C a r r o l l , Davis, and Richman (1971). Dep = ratings of depression from a scale from 1 to 9 where higher ratings denote adjectives highly descriptive of depression. Ratings are taken from Myers (1984). 83 the target words w i l l be discussed in the context of the recognition task. Recognition test. The recognition test is presented in Table 2 of Appendix I. The test contained the two sets of target words, as well as two sets of distractor words, l i s t e d in Table 3. The dis t r a c t o r words were selected so that they were matched in frequency and ratings of descrlptiveness of depression with the c r i t i c a l l i s t . To confirm that the c r i t i c a l and distr a c t o r l i s t s had the desired properties, a four between-groups (depression-target, depresslon-distractor, positive-target, and pos i t i v e - d i s t r a c t o r ) MANOVA was conducted with word frequency and depression descrlptiveness ratings as dependent measures. The s i g n i f i c a n t MANOVA (Wilk's lambda(6,110) = .0068, p_ < .001) was followed with univariate ANOVAs for each dependent variable. The nonsignificant ANOVA for word frequency, F(3,56) = .86, p_ > .05, suggests that the four types of words did not d i f f e r s i g n i f i c a n t l y with respect to their average frequencies. As expected, the groups of words were distinguishable with respect to their ratings of depression, F(3,56) = 2690.54, p_ < .001. Tukey comparisons showed that the depression-target words had s i g n i f i c a n t l y higher ratings of depression than the positive-target words, g(4,56) = 90.85, p. < .05. However, the two depression l i s t s did not d i f f e r s i g n i f i c a n t l y from each other with respect to their ratings of depression, g(4,56) = 1.39, p_> .05. Likewise, the two positive l i s t s did not d i f f e r s i g n i f i c a n t l y with respect to their ratings of depression, g(4,56) = .71, p. > .05. Reaction time probes. The presentation of the word "PRESS" served as a reaction time probe. Procedure Subjects were instructed as follows: For t h i s task, you w i l l be asked to put on these earphones. Your task is to repeat aloud everything you hear in your right ear. Try to do t h i s as quickly as you can without making mistakes. Ignore anything that might be said on the l e f t ear. At the same time, take a look at the computer screen. Most of the time, a • i + H v i l l appear on the center of the screen. Sometimes, the "+" w i l l disappear, and the word "PRESS" w i l l appear instead. Whenever you see the word "PRESS", press this button (a key on a computer keyboard). Try to do this as quickly as you can but don't forget, the most Important thing to do is to repeat whatever is being said In your right ear. Are there any questions? Let's s t a r t with some practice s t o r i e s . The s t o r i e s were presented in the right hand channel, whereas the sets of words appeared in the l e f t hand channel. To ensure that the volume levels for both channels were roughly equivalent, the experimenter matched the volumes of each channel by l i s t e n i n g to each in turn, then switching the channels to avoid any right ear bias. The unattended 85 words presented in the l e f t hand channel are processed by the r i g h t cerebral hemisphere. It has been suggested that the right cerebral hemisphere plays a s a l i e n t role in the processing of a f f e c t i v e disorders (cf. Bryden & Ley, 1983; Heilman, Watson, & Bowers, 1983). Two practice stories were given, in which neutral words were presented in the unattended channel. The four target -stories followed. Two of the four stories were paired with the depression-related words in the unattended channel, while the other two stories were paired with the positive words. The presentation of the words was in synchrony with the presentation of the st o r i e s . This was achieved by the experimenter starting the tape recorder and the computer program at the same time. To allow subjects to adequately orient themselves to each story, a 7 second Introductory phase was presented for each story. The introductory phase consisted of 2 seconds of silence, followed by the presentation of five neutral words. The c r i t i c a l words followed. Thus, the c r i t i c a l l i s t began 7 seconds after the story's onset and ended 3 seconds before the story finished. The i n i t i a l presentation of the neutral words in the Introductory phase ensured that the c r i t i c a l words did not a t t r a c t undue attention by emerging from a s i l e n t background. A l l possible orders of stimulus presentation were used. The order of story presentation was arranged into four 86 d i f f e r e n t sequences, with each story paired with both types of words. This arrangement created eight possible sequences. The orders were arranged sequentially on a l i s t , where the f i r s t subject received the f i r s t order, the second subject received the second order and so on, u n t i l the l i s t was exhausted. At t h i s point, the next subject received the f i r s t order and so on. As well, the sequence of presentation of the unattended words was randomly determined, and was d i f f e r e n t for each story. Concurrent with the dichotic l i s t e n i n g task, subjects were required to perform a simple reaction time task. They were asked to fixate on a "+", presented c e n t r a l l y on a computer screen. Subjects were asked to respond whenever the word "PRESS" replaced the "+" by pressing a response key on the computer keyboard. Three probes - the word "PRESS" - were presented for each story. The presentation of a probe coincided with the presentation of a c r i t i c a l word in the unattended channel. Since the probes appeared during the presentation of the c r i t i c a l words, no probe stimulus appeared in the f i r s t 7 seconds or the l a s t 3 seconds of each story. The remaining 15 seconds were divided into three blocks of f i v e ; a probe could appear anywhere within this Interval, with the constraint that no two probes appeared within 3 seconds of each other. The experimenter listened to each shadowed story with Its s c r i p t at hand. The experimenter kept track of the 87 number and type of shadowing errors by crossing off a l l missed or misstated word on the s c r i p t . The probe detection latencies were recorded by the computer. Subjects were then given the recognition test . They were instructed: In the l e f t hand channel that you were supposed to ignore, there were some words presented on that channel. Here is a l i s t of words. Were any of these words on that channel? If you are unsure, take a guess. Don't be af r a i d to guess and don't spend too much time on any one word. Hypotheses (a) The presence of the depressive schema would f a c i l i t a t e processing of depression-related s t i m u l i . Thus, currently depressed Individuals would take less resources to process unattended depression words, leading to less Interference of ongoing tasks. Compared to nondepressed nonscheraatic individuals, currently depressed subjects would have shorter probe detection latencies and fewer shadowing errors during stories with unattended depression- related words. An opposite pattern was expected for nondepressed nonschematic individuals for the positive unattended words. (b) Depressive automatic processes are v u l n e r a b i l i t y markers. Thus, the pattern Of performance of remitted depressed individuals would resemble those of the currently depressed subjects. (c) The unattended material i s processed unconsciously. A l l groups of subjects would show chance performance on the recognition task. Results Analyses The dependent measures were averaged probe reaction times and the number of shadowing errors. The analysis of variance involved a two-factor mixed design, which consisted of groups (CDG, RDG, NDG) as a between-subjects factor, and word types (depression, positive) as a within-subjects factor. Recognition performance was scored by counting the number of false alarms (incorrect endorsements) and hits (correct endorsements). The analysis of variance design for the recognition task is a three-factor mixed one, consisting of groups (CDG, RDG, NDP), word types (depression, positive) and response types ( h i t s , false alarms). The f i r s t factor is between-subjects, while the l a s t two factors are within-subjects. Probe reaction time. The probe reaction times are presented in Table 4, whereas the results of the analysis of variance are summarized in Table 1 of Appendix J. The analysis of variance showed that there were nonsignificant main effects for word types, F(l,57) = .08, p_ > .10, and groups; F(2,57) = 2.38, p_ > .05. However, there was a s i g n i f i c a n t interaction between groups and word types, 89 Table 4 Detection Latencies from the Dichotlc Listening Task ln  Msecs 1 CDG RDG NDG Content Condition Depression M 5 0 6 . 7 5 4 8 6 . 8 5 4 7 6 . 4 0 SD ( 1 4 9 . 0 6 ) ( 1 4 5 . 9 2 ) ( 2 5 0 . 2 1 ) Positive M 5 7 5 . 8 0 4 9 5 . 8 0 3 7 8 . 5 0 SD - ( 2 7 6 . 9 7 ) ( 1 6 9 . 3 4 ) ( 6 4 . 1 1 ) Note. CDG = Currently depressed group. RDG = Remitted depressed group. NDG = Nondepressed group. 90 F(2,57) = 4.17, p_ < .05. This interaction is i l l u s t r a t e d in Figure 1. In l i g h t of the s i g n i f i c a n t Interaction effect, comparisons were conducted to examine the predictions from the f i r s t and second hypotheses. To r e i t e r a t e , i t Was hypothesized that the two depressed groups would have quicker probe detection latencies associated with the depression-content words, while nondepressed subjects would show the reverse pattern. Thus, within-groups comparisons conducted across the two word types were warranted. Tukey comparisons showed that both depressed groups did not d i f f e r e n t i a l l y process across the two word types: CDG: g(3,57) = 2.36, p. > .05; RDG: g(3,57) = .31, p_ > .05. Tukey's test for the NDG, g(3,57) = 3.34, just missed s t a t i s t i c a l significance at the p_ = .05 level but was s i g n i f i c a n t at the p = .10 l e v e l , suggesting that nondepressed subjects had s l i g h t l y shorter detection latencies associated with the positive-content than the depression-content words. Correlation analysis. As seen ln Figure 1, the two depressed groups appeared to have overal l longer reaction times to the visual probe. The p o s s i b i l i t y exists that slowed reaction times may be attributed to the older ages associated with the two depressed groups (cf. Albert, 1981), or as a function of the severity of depression (cf. Freldman, 1964). To test for t h i s p o s s i b i l i t y , Pearson-product moment correlation c o e f f i c i e n t s were computed for 91 Figure 1. Detection latencies from the dichotic listening task. o LU co >-o z LU 600-500 -400 -•— Currently depressed group A Remitted depressed group • Nondepressed group 300 Depression Positive CONTENT CONDITION 92 the overal l reaction times with BDI scores and age for a l l subjects and for the c l i n i c a l subjects alone. None of the values were of an acceptable magnitude. For a l l subjects, the c o r r e l a t i o n c o e f f i c i e n t s were .25 and .21 (both p_ > .05, df = 58) for, respectively, reaction times with age and reaction times with BDI scores. For the analysis with the two depressed groups alone, the correlations were even lower: .12 (reaction time with age), and .10 (reaction time with BDI). Thus, i t is unlikely that the slowed reaction times of the two depressed groups were due to increased age or severity of depression, but perhaps are more l i k e l y due to d e b i l i t a t i n g effect of the presence of positive words In the unattended channel. Shadowing performance. The shadowing performance for each group Is summarized in Table 5, whereas the results of the analysis of variance are presented in Table 2 of Appendix J. Of central interest, the analysis of variance showed a nonsignificant group x word type interaction e f f e c t , F(2,57) = .30, p_ > .10, suggesting that this measure was insensitive measure of the depressive schematic e f f e c t . Recognition task performance. The data for the recognition h i t rate are presented in Table 6. Despite the encouragement to guess, subjects were reluctant to do so, as evidenced by a low overall "yes" response rate (M = 1.51 out of a possible 60 items). This r e s u l t substantiates subjects' claims that they did not hear the words In the unattended channel. Table 5 Mean Number of Shadowing Errors CDG RDG NDG Content Condition Depression M .45 .45 1.20 SD (0.95) (0.85) (2.26) Positive M .45 .85 1.15 SD (0.51) (1.27) (1.66) Note. CDG = Currently depressed group. RDG = Remitted depressed group NDG = Nondepressed group. Table 6 Mean Number of word3 RecognW.eri CDG RDG NDG Content Condition Hits Depression M 1.70 1.35 3.60 SD (3.05) (2.01) (3.54) Positive M .95 .60 2.20 SD (2.06) (1.14) (3.44) False positives Depression M 1.15 .40 2.24 SD (2.34) ( .68) (3.4.S) Positive M 1.05 .50 2.20 SD (2.14) (1.10) (3.41) Note . CDG = Currently depressed group, RDG = Remitted depressed group. NDG = Nondepressed group. 95 The analysis of variance, l i s t e d in Appendix J - Table 3, produced several s i g n i f i c a n t e f f e c t s . F i r s t , there was a s i g n i f i c a n t main eff e c t for groups, F(2,57) = 4.14, p_ < .05. However, Tukey tests showed no s i g n i f i c a n t groupwise comparisons: CDG vs. NDG: g(3,57) = 1.90, p_ > .05; CDG vs. RDG: g(3,57) = .71, p_ > .05; RDG vs. NDG: g(3,57) = 2.64, p_ > .05. Of more theoretical; interest, there was a significant-main ef f e c t for response, F(l,57) = 14.01, p_ < .001, with subjects making more hit s than false alarms (3.46 vs. 2.48). Thus, subjects had above chance recognition of the presented words. However, no group appeared to be better than any other group at c o r r e c t l y recognizing the presented words, as indicated by the nonsignificant group x response Interaction, (F(2,57) = .86, p> > .05), and the nonsignificant group x response x content interaction (F( 2, 57 ) = . 37, p_ > ,05) . Summary The f i r s t hypothesis states that the presence of a depression schema would f a c i l i t a t e the processing of the unattended depression-related s t i m u l i . Contrary to the f i r s t hypothesis, neither currently depressed nor remitted depressed subjects showed quicker probe detection latencies when depression-related words were presented in the unattended channel. Rather, they showed an even-handedness in their processing of the s t i m u l i : they had similar detection latencies associated with both the depression- and positive-content s t i m u l i . In contrast, nondepressed subjects d i f f e r e n t i a l l y process the two word conditions. At p_ = .10 l e v e l , these subjects reacted to the probe quicker when positive words were presented in the unattended channel, compared to the depression-content words, shadowing performance, in general, was not a sensitive indicator of depressive processing bias. That i s , the pattern of errors across the three groups was highly s i m i l a r . The second hypothesis states that depressive automatic processes, as assessed by the dichotlc l i s t e n i n g task, constitute v u l n e r a b i l i t y markers. In support of the second hypothesis, the pattern of processing of the remitted depressed subjects was more similar to the currently depressed subjects than the nondepressed subjects. The third hypothesis states that the processing of the unattended material is nonconscious. The t h i r d hypothesis was not supported. Despite subjects' subjective reports of not hearing the unattended words, they showed above chance performance on the recognition task. chapter 8: vis u a l Probe Task This task, adapted from MacLeod, Mathews, and Tata (1986), was designed to measure the d i s t r i b u t i o n of v i s u a l attention. Pairs of words were presented on a computer screen, one appearing in the upper half of the screen, and the other appearing in the lower half of the screen. There were three types of word pairs: neutral-neutral, depression-neutral, and positive-neutral. Subjects were asked to read the top word aloud. Subjects were also given a secondary reaction time task of responding to a probe, a "+" which appeared on either location of the words, as quickly as possible. The d i s t r i b u t i o n of v i s u a l attention is inferred by the pattern of detection latencies of the probes. Subjects have shorter detection latencies for targets that are in their attentional f i e l d s , and take longer If their attention had been drawn elsewhere (Navon & Margal1t, 1983). Depressed schematic individuals, t h e o r e t i c a l l y , have a processing bias that favors the encoding of depression-related s t i m u l i . Depressed schematic individuals, r e l a t i v e to nondepressed nonschematic individuals, are hypothesized to s h i f t t h e i r attention towards the depression-words, resulting in reduced detection latencies for probes appearing in the v i c i n i t y of such s t i m u l i . This e f f e c t can be explained by examining the sample t r i a l s in which the depression words are presented in the lower part of the screen. Subjects are required to read the top word aloud, thus div e r t i n g their attention to the top words. However, the presence of the depression-related word in the bottom half of the screen would lead depressed Individual to s h i f t their attention toward the bottom location. Since their attention had been drawn to the bottom location of the screen, depressed schematic Individuals would be quicker to detect probes presented in the bottom half of the screen compared to probes presented in the upper part of the screen. Method Materials Three sets of words pairs were presented. These, l i s t e d in Table 7, were: depression-neutral, p o s i t i v e -neutral, and neutral-neutral. There were 14 word pairs in each set. None of the words used in the dichotlc l i s t e n i n g task appeared in this task. The depression-related and positive adjectives were selected for, respectively, their high and low ratings of descrlptiveness of depression, as provided by Cheung (1987). As well, there was an attempt to equate the l i s t s with respect to word length (number of l e t t e r s in a word) and word frequency, as both have been shown to a f f e c t reaction times to words (e.g., Morton, 1969; Scuberth, Spoehr, & Lane, 1981). Analyses confirmed that these sets of words had the desired properties. F i r s t , an analysis of variance showed that the depression-related words had s i g n i f i c a n t l y higher ratings o£ depression than the positive words, F ( i , 2 6 ) = 99 Table 7 Stimulus Words for Visual Probe Task Depresslon- WL WF D Matched WL WF content Neutral blue 4 1071 4.13 t a l l 4 848 defeated 8 96 4.24 mounted 7 132 depressed 9 14 4.96 academic 8 19 desolate 8 25 4.31 gradual 7 26 despondent 10 2 4.13 1ightened 9 2 dismal 6 22 ,4.09 dainty 6 22 downcast 8 6 4.27 cluttered 9 6 dreary 6 19 3.93 braided 7 17 1i feless 8 17 4.16 barefoot 8 17 mournful 8 16 4.20 guessing 7 19 sad 3 309 4 . 58 dressed 7 310 sluggish 8 6 3.67 masculine 9 7 sorrowful 9 13 4.16 feminine 8 12 dejected 8 4 4 . 56 shaven 4 6 M 7.36 115.7 4.24 7 .14 103.1 SD 1.95 286.5 .32 1 .61 229 . 8 Pos itive-content Matched neutral assertive 9 7 1.20 cluttered 9 6 attentive 9 10 1. 09 Immigrant 9 11 cheerful 8 87 1.04 accompanied 11 76 conf ident 9 37 1.07 motionless 10 43 dynamic 7 28 1.09 focused 7 27 gi fted 6 16 1.09 hushed 6 17 happy 5 774 1.02 moving 6 871 industrious 11 8 1.11 lengthened 10 10 loved 5 347 1.13 nearby 6 335 product ive 10 4 5 1.09 addressed 9 49 rested 6 88 1. 38 greeted 7 70 secure 6 75 1.16 hurrying 9 69 s p i r i t e d 8 13 1.04 hunched 7 14 thr ivlng 8 29 1.12 loosened 8 26 M 7 .64 111.7 1.12 8 .14 116.0 SD 1 .86 209.6 .09 1 .66 232.8 Neutral Matched neutal abroad 6 155 brief 5 160 accustomed 10 55 neutral 7 53 evasive 7 2 jumbo 5 3 accented 8 124 shiny 5 123 allowed 7 278 dressed 7 310 corny 5 4 shaven 6 4 cramped 7 14 lending 7 12 curly 5 44 junior 6 44 guided 6 46 urban 5 50 table continued on next page . . . 100 hidden 6 210 landed 6 178 indoor 7 10 pauslng 7 11 lean 4 99 mild 4 115 quenched 8 3 squeaky 7 3 loudly 6 124 recal1 6 138 M 6.57 83.43 5.93 86.00 SD 1.50 85.90 1.00 89.78 Note. WL = word length (number of l e t t e r s in a word) WF = word frequency. These ratings are from C a r r o l l , Davis, and Richman (1971). D = ratings of depression on a scale from 1 to 5 where higher ratings are highly desciptive of depression. These ratings are taken from Cheung (1987). 101 1338.21, p_ < ,001. Furthermore, analyses of variance suggested that the l i s t s were not distinguishable from one another in either word length, F(5,78) = 1.78, p. > .10, or word frequency, F(5, 78) = . 33, p_ > .10. Procedure Subjects were given the following set of instructions, which were modified from those in MacLeod et a l . (1986): For t h i s task, you are going to see words presented on the screen in pairs. One word w i l l appear just above the center of the screen and one just below. Read the top word aloud as soon as i t appears. Sometimes when the two words disappear, a small "+" w i l l appear either in the area where the top word appeared or where the bottom word appeared. When you see the "+", press this button [a response key on a computer keyboard] as quickly as you can. Are there any questions? Subjects were f i r s t given a set of practice t r i a l s c onsisting of 10 pairs of neutral words and three probes. The three sets of 14 word pairs were presented t h r i c e , producing a t o t a l of 126 t r i a l s . Forty-two of the 126 t r i a l s contained probes, with 14 probes appearing for each word set. To avoid any potential order e f f e c t , each subject received a d i f f e r e n t sequence of the presentation of the word p a i r s . The s t i m u l i were presented on a microcomputer. A dot, presented c e n t r a l l y on the screen, served as a fi x a t i o n 102 point. The dot remained on the s c r e e n for 500 msec. The dot then disappeared, and the word pair was presented. One word appeared just above the center of the screen and one just below. The words remained for 500 msec. On t r i a l s not containing the probe, the f i x a t i o n point reappeared. On probed t r i a l s , the "+" appeared approximately 25 msec after the termination of the word display. The probe remained on the screen u n t i l the subject responded by pressing a key on a computer terminal. Detection latencies were recorded by the microcomputer. Hypotheses (a) Depressed in d i v i d u a l s , compared to nondepressed individuals, would have shorter response latencies to probes that were preceded by depression-related words In the v i c i n i t y . S i m i l a r l y , depressed individuals would have longer response latencies to probes when preceded by depression-related words presented in a d i f f e r e n t location. (b) Nondepressed individuals, compared to depressed individuals, would have shorter response latencies to probes that were preceded by positive words in the v i c i n i t y . Likewise, nondepressed Individuals would have longer v response latencies to probes that were preceded by positive words in the v i c i n i t y . (c) The pattern of processing of the depression-related information for the remitted subjects would resemble that of the currently depressed subjects. 103 Results AnalysIs The dependent measure was averaged probe d e t e c t i o n l a t e n c y . The a n a l y s i s o£ variance Involved a f o u r - f a c t o r mixed d e s i g n , which c o n s i s t e d of groups (CDG, RDG, NDG), word, type (depression, p o s i t i v e , n e u t r a l ) , and word p o s i t i o n (upper, lower), and probe p o s i t i o n (upper, lower). The f i r s t f a c t o r was between-subjects, while the other three f a c t o r s were w i t h i n - s u b j e c t s . -Missing data For each s u b j e c t , there were 12 p o s s i b l e (three types of t a r g e t word x two p o s i t i o n s of the t a r g e t words x two probe p o s i t i o n ) types of s t i m u l i . For the p r e s e n t a t i o n of each t a r g e t , the computer program randomly determined the p o s i t i o n of the t a r g e t words and the p o s i t i o n of the probe. Thus, i t i s p o s s i b l e t h a t f o r any one s u b j e c t , the program f a i l e d t o generate a l l p o s s i b l e types of s t i m u l i . A small percentage of the t o t a l p o s s i b l e t r i a l s a c r o s s a l l s u b j e c t s were not presented (1.24% or 12/960). As suggested by Kirk (1982), these m i s s i n g data were estimated by t a k i n g the group average to which that subject belonged for the missing c o n d i t i o n . 104 Detection latencies The detection latencies are presented in Table 8, whereas the results of the analysis of variance are presented in Appendix K. Contrary to predictions, the group x word type x word position x probe position interaction e f f e c t was not s i g n i f i c a n t , F(4,114) = 1,14, p_ > ,10. However, there was a s i g n i f i c a n t main effect for groups, F(2,57) = 4.59, p_ < .05. However, Tukey tests showed no s i g n i f i c a n t groupwise comparisons: CDG vs. NDG: 500.03 vs. 395.10 msec, g(3,57) = 1. 38, p. > .05; CDG vs. RDG: 500.03 vs. 469.87, g(3,57) = .40, p_> .05; RDG vs. NDG: 469.87 vs. 395.10, g(3,57) = .98, p_ > .05. As expected, there was a main effect of probe position, F(l,57) = 34.53, p_ < .001, with shorter latencies for detecting the probe when presented on the upper part rather than the bottom part of the screen (415.26 vs. 484.52 msec), in addition, there was a s i g n i f i c a n t content x word position Interaction e f f e c t , F(2,114) = 3.33, p_ < .05. No other effects were s i g n i f i c a n t . ( Summary The c r i t i c a l Interaction effect f a i l e d to reach s t a t i s t i c a l s i g n i f i c a n c e . This f a i l u r e may be due to the r e l a t i v e l y small sample s i z e . However, th i s is unlikely to be the case. Using an even smaller sample size (n = 16 for each experimental group), MacLeod et a l , (1986) used a similar paradigm to demonstrate attentive biases in their samples of anxious patients and normal controls. 105 Table 8 Mean Probe Detection Latencies In Msec CDG RDG NDG Word Condition 1 1 BU 1 UU UB BU BB UU UB BJJ BB Depression M 438 520 422 533 374 540 391 512 369 422 393 421 SD 143 133 127 167 68 220 60 119 75 107 85 76 Positive M 433 533 486 576 411 450 465 470 380 407 403 386 SD 108 264 181 245 95 169 106 121 81 94 150 70 Neutral M 406 520 489 540 442 521 428 510 385 437 361 424 SD 120 163 202 217 155 147 109 145 75 110 68 62 Note. CDG = Currently depressed group. RDG = Remitted depressed group. NDG = Nondepressed group. UU = target word In top position followed by top probe. UB = target word in top position followed by bottom probe. BU = target word in bottom position followed by top probe. BB = target word in bottom position followed by bottom probe. 106 The f a i l u r e to reach s t a t i s t i c a l significance may be due to the large v a r i a b i l i t y associated with the currently depressed group. Table 8 shows the standard deviations across the various conditions ranged from 70 to 150 for the nondepressed group's data, and ranged from 60 to 155 for the remitted depressed group's data. The currently depressed group's standard deviations, which ranged from 108 to 245, represented far more v a r i a b i l i t y than the other two groups. This large v a r i a b i l i t y may simply r e f l e c t the heterogeneity of the currrently depressed subjects themselves. That i s , these subjects came from several psychiatrists who among themselves, may attra c t d i f f e r e n t patient populations and may have used d i f f e r e n t treatments. This hypothesis seems plausible in l i g h t of the r e l a t i v e l y small v a r i a b i l i t y associated with the data from the remitted depressed subjects, of which the majority were seen and treated by one p s y c h i a t r i s t . It is suggested that any studies considering using t h i s paradigm with depressed samples aim to reduce the v a r i a b i l i t y of the subject groups. 107 Chapter 9: I m p l i c i t Memory Task T h i s task, adapted from Graf, Shiraamura, and s q u i r e (1985), c o n t r a s t e d i m p l i c i t with e x p l i c i t memory f o r d e p r e s s i o n - r e l a t e d i n f o r m a t i o n . As d i s c u s s e d e a r l i e r , i m p l i c i t memorial processes are con s i d e r e d to be r e l a t i v e l y automatic and independent of conscious awareness, whereas e x p l i c i t memory r e q u i r e s e l a b o r a t i v e processes. I t was noted p r e v i o u s l y that the l i t e r a t u r e has, at best, found i n c o n s i s t e n t r e s u l t s f o r d e p r e s s i v e memorial bias e s using e x p l i c i t memory t a s k s . However, I hypothesize that more promising r e s e a r c h s t r a t e g i e s l i e l n those i n v o l v i n g automatic processes. I t i s , t h e r e f o r e , hypothesized t h a t memorial biases f o r i n f o r m a t i o n r e l a t e d to depression i n depressed schematic i n d i v i d u a l s would be evident i n an i m p l i c i t , but not i n an e x p l i c i t , memory task. Method M a t e r i a l s Four content c a t e g o r i e s were used. Within each category, there were f i v e exemplars. The category l a b e l s and the exemplars (presented Inside the parentheses) were: Happiness ( j o y f u l , e n e r g e t i c , contented, s m i l i n g , f r i e n d l y ) , Depression (hopeless, l e t h a r g y , t i r e d , l o n e l y , i n d i f f e r e n t ) , Flowers ( l i l a c , sunflower, marigold, snapdragon, poppy), and Diseases ( m a l a r i a , f l u , d i a b e t e s , a r t h r i t i s , l e p r o s y ) . The l a t t e r two word types were s e l e c t e d as they have, r e s p e c t i v e l y , p o s i t i v e and negative a f f e c t i v e a s s o c i a t i o n s , but are not s p e c i f i c a l l y r e l a t e d to d e p r e s s i o n i n content. 108 The inclusion o£ these affect-laden words Is to counter the p o s s i b i l i t y that any memorial biases for the depression and the positive words could be s o l e l y attributable to the role of a f f e c t . The stimulus words were drawn from two sources. Exemplars for the Flower and Disease categories came from Battlg and Montague (1969). These investigators collected norms from 442 subjects on the frequency of producing exemplars for a number of categories. To avoid c e i l i n g and floor effects on the category production tasks, exemplars were chosen that were neither frequently nor Infrequently produced. Based on the 442 subjects, the selected exemplars had an overall production frequency of 34.2 (SD = 12.82) with a range of 17 to 54. The Flower exemplars had an overall average production frequency of 29.2 (S_D = 11.26) with a range of 17 to 45, whereas the Disease exemplars had an o v e r a l l average production frequency of 39.2 (SD = 13.45) with a range of 24 to 54. Exemplars for the Depression and Happiness categories came from 18 subjects, who were university students. These subjects were given the instructions: The purpose of this exercise is to find out what words or adjectives people usually give as being representative of various emotions (Depression and Happiness). Write down as many adjectives or descriptive terms of these emotions as you can. write them In any order. Allow yourself a couple of minutes 109 per emotion. Based on the 18 subjects, the exemplars selected for use in the present study had an overall average production frequency of 6.2 (SD = 1.75) with a range of three to nine. The Happiness exemplars had an overall average production frequency of 6.2 (SD = 2.28) with a range of three to nine. Sim i l a r l y , the Depression exemplars had an overall production frequency of 6.2 (SD = 1.30) with a range of five to eight. Procedure Half of the subjects within each group were in the primed condition. For this condition, subjects rated the l i s t of stimulus words on how much they liked each word. Words were presented verbally, one at a time. The rate of presentation was ind i v i d u a l l y t a i l o r e d , depending on how long subjects took to rate each word. Five practice words were presented f i r s t , which were unrelated to any of the categories. Subjects then completed the category production task using the following instructions, which were modified from Graf et a l . (1985): Now we w i l l do something d i f f e r e n t . I'm going to give you a t i t l e - the name of a category. I want you to say eight things that belong to that category as fast as you can. For example, If the category is " r e l a t i v e " , some things that belong to that category might be aunt, uncle, and s i s t e r . Now you give some examples (Subjects provided examples). Now, the next 110 category label is __. Give eight exemplars that belong to that category. (The category t i t l e s Depression, Happiness, Flowers, and Diseases were presented. To avoid sequence e f f e c t s , subjects received one of the eight possible orders of presentation). Subjects* responses were recorded. Next, subjects were given the e x p l i c i t memory task with the instructions: Fine. Now I'm going to ask you to r e c a l l as many words as you can from the l i s t that you were asked to rate. Write those words on thi s piece of paper. Recall as many as you can, and r e c a l l them in any order that you please. Go ahead. The remaining half of the subjects were in the unprlmed condition, and were given only the category production test. These data provided a baseline against which the previously primed production data were compared. The assignment of subjects in the primed or unprlmed conditions was determined randomly, with the constraint that equal proportions within the three.subjects groups appeared in each condition. Hypotheses (a) There would not be a d i f f e r e n t i a l r e c a l l rate for the di f f e r e n t categories for any of the three subject groups. (b) In contrast to the above, depressed schematic Individuals would show a greater effect of priming for the depression-content words than nondepressed nonschematic I l l i n d i v i d u a l s . A s i m i l a r p a t t e r n was e x p e c t e d f o r the nondepressed nonschematic s u b j e c t s f o r the h a p p i n e s s - r e l a t e d words. (c) I m p l i c i t memorial processes are s e n s i t i v e measures of v u l n e r a b i l i t y markers for de p r e s s i o n . The re m i t t e d depressed i n d i v i d u a l s ' p a t t e r n of r e s u l t s would resemble those of the c u r r e n t l y depressed i n d i v i d u a l s . R e s u l t s A n a l y s i s From the i m p l i c i t memory task, the dependent measure was the number of t a r g e t words produced on the generation task. The design was a t h r e e - f a c t o r s mixed a n a l y s i s of v a r i a n c e , c o n s i s t i n g of groups (CDG, RDG, NDG) and c o n d i t i o n s (primed, unprlmed) as between-subjects f a c t o r s , and c a t e g o r y type (depression, happiness, flower, disease) as a w i t h i n - s u b j e c t s f a c t o r . From the e x p l i c i t memory task, the dependent measure was the number of words c o r r e c t l y r e c a l l e d by sub j e c t s i n the primed c o n d i t i o n s . The a n a l y s i s of v a r i a n c e involved a two-factor mixed design, which c o n s i s t e d of groups (CDG, RDG, NDG) as a between-subjects f a c t o r , and category type (depression, happiness, flower, d i s e a s e ) as a w i t h i n -s u b j e c t s f a c t o r . Scoring In both the word generation and r e c a l l t a s k s , s u b j e c t s o c c a s i o n a l l y changed the s u f f i x of the st i m u l u s word without changing i t s meaning (e.g., joyous c o u l d have been used f o r j o y f u l ) . Two methods of scoring were therefore carried out: one which scored these as errors, and a more lenient system which counted these as correct. Analyses from the two methods were e s s e n t i a l l y the same. For this reason and to be consistent with other similar studies (e.g., Graf et a l . , 1985; Mathews, Mogg, May, & Eysenck, 1989), only the results from the s t r i c t scoring system are reported. Implicit Memory Task The means for the production task are presented in Table 9. The results of the ANOVA are summarized in Appendix L - Table 1. As expected, a s i g n i f i c a n t main effect was found for priming, F(l,54) = 18.41, p_ < .001, indicating that the words presented ln the primed condition lead to a greater probability of being produced in the production task (1.61 vs. .86). More importantly, however, there was a nonsignificant interaction between group and priming condition, F(2,54) = 1.15, p_ > .10, suggesting that the groups were roughly similar in their a b i l i t i e s to show the priming e f f e c t . The priming condition x category interaction barely reached significance, £(3,162) = 2.69, p_ < .05, with Greenhouse-Geisser correction. of central t h e o r e t i c a l interest, there was a s i g n i f i c a n t three-way interaction between group x category type x priming, F(6, 162) = 2.24, p_ < .05. Predictions from hypotheses 2 and 3 suggest within-group follow-up comparisons across the d i f f e r e n t content conditions. 113 Table 9 Number of Words Generated in the Implicit Task CDG RDG NDG UP P UP P UP P Category Condition Depression M .73 1. ,33 .67 1. ,64 1. ,67 ,82 SD ( ' .64) ( . ,71) ( .71) ' (1. ,21) (2. ,83) ( '. ,75) Happiness M .82 1. ,67 .67 1. .82 1. ,78 1. .54 SD ( .60) (1. , 32) ( .70) ( . .87) ( , .97) (1. .04) Flower M .27 1, .56 .67 1, .27 . 56 2, .18 SD ( .47) (1. .33) ( .86) (1. .42) ( • .73) (1. .25) Disease M .73 1, .78 .56 1. .54 1. .22 2, .18 SD ( .79) (1 .09) ( .73) (1 .21) ( .44)(1, .08) Notes. CDG = Currently depressed group. RDG = Remitted depressed group. NDG = Nondepressed group. UP = unprlmed condition. P = primed condition. 114 However, an examination of Table 9 suggests that such an a n a l y s i s would c o n t r i b u t e l i t t l e to the c l a r i f i c a t i o n of the nature of the i n t e r a c t i o n e f f e c t , that i s , a l l three groups generated more.previously r a t e d h a p p i n e s s - r e l a t e d words than d e p r e s s i o n - r e l a t e d words. A comparison between groups w i t h i n content c o n d i t i o n s produced more promising e f f e c t s . To l i m i t the t o t a l number op a n a l y s e s , thereby l i m i t i n g the p o s s i b i l i t y of Type 1 e r r o r s , between-groups comparison were conducted on the c r i t i c a l c o n d i t i o n s of d e p r e s s i o n and happiness c a t e g o r i e s . For the depression category, Tukey comparisons suggest that the RDG showed more of a priming e f f e c t than the NDG, g(3,162) = 3.74, p. < .05, but d i d not d i f f e r e d s i g n i f i c a n t l y from the CDG, g(3,162) = .51, p_ > .05. Unexpectedly, the comparison between the CDG and the NDG d i d not approach s i g n i f i c a n c e , g(3,162) = 2.32, p_ > -05. A s i m i l a r a n a l y s i s conducted for the happiness category, unexpectedly, showed no group d i f f e r e n c e s : CDG vs. NDG: g(3,162) = .59, p_ > .05; CDG vs. RDG: g(3,162) = .68, p_ > ,05; RDG vs. NDG: g( 3,162) = 1.28, p_ > .05. In a d d i t i o n , the o v e r a l l a n a l y s i s of v a r i a n c e produced n o n s i g n i f i c a n t main e f f e c t s f o r groups, F(2,54) = 2.17, p_ > .10, and category type, F(3,162) = 1.30, p_ > .10. As w e l l , there was a n o n s i g n i f i c a n t i n t e r a c t i o n between group by category type, F(6,162) = .29, p_ > .10. 115 E x p l i c i t Memory Data. The means from t h i s task are presented i n Table 10, whereas the a n a l y s i s of v a r i a n c e r e s u l t s are presented i n Table 2 of Appendix L. Of c e n t r a l t h e o r e t i c a l importance, there was a n o n s i g n i f i c a n t group x category type i n t e r a c t i o n , F(6,81) = .88, p_ > .10, which supports the hypothesis that the e x p l i c i t memory task i s an i n s e n s i t i v e memorial measure of schematic p r o c e s s i n g . There was a n o n s i g n i f i c a n t o v e r a l l e f f e c t f o r groups, F(2,28) = .30, p. > .10, negating the p o s s i b i l i t y t h a t the depressed group showed any memory d e f i c i t s . In a d d i t i o n , there was a s i g n i f i c a n t main e f f e c t f o r categor y type, F(3,81) = 28.52, p_ < .001. Since t h i s e f f e c t was not of t h e o r e t i c a l i n t e r e s t , follow-up comparisons were not conducted. Summary C o n s i s t e n t with p r e d i c t i o n s from f i r s t h y p o t h e s i s , the e x p l i c i t memory task was an i n s e n s i t i v e measure of p o t e n t i a l schematic p r o c e s s i n g . With r e s p e c t to the second and t h i r d hypotheses, the s e n s i t i v i t y of the i m p l i c i t memory task was somewhat supported. As p r e d i c t e d , remitted depressed s u b j e c t s showed a gr e a t e r priming e f f e c t than the nondepressed s u b j e c t s f o r depression-content s t i m u l i . This r e s u l t could not have been due to the remitted depressed s u b j e c t s ' greater p r o p e n s i t y f o r priming, because they d i d not show s u p e r i o r priming f o r the other c a t e g o r i e s . U n f o r t u n a t e l y , the r e s u l t s are weakened by two unexpected r e s u l t s . F i r s t , the c u r r e n t l y depressed s u b j e c t s d i d not Table 10 Number of words Recalled for the E x p l i c i t Task CDG RDG NDG Category Condition Depress ion M .89 .45 1, .09 SD (li ,05) ( '. .52) (1. ,22) Happiness M 1, , 22 1, .09 1. ,00 SD (1. .09) ( , .83) (2. ,54) Flower M 2, .11 . 2, .55 2, ,55 SD (1, .27) (1, .37) (1. ,63) Disease M 2. .11 2, .18 2, ,64 SD (1. .17) (1. .32) ( . ,67) Note. CDG = Currently depressed group. RDG = Remitted depressed group. NDG = Nondepressed group. \ 117 show thi s effect, second, no group differences were observed for the positive s t i m u l i . 118 Chapter 10: Self-Report of Cognitions This chapter focuses on s e l f - r e p o r t of cognitions. In contrast to the automatic tasks used by t h i s thesis, these cognitions are readily accessible to conscious awareness, and thus are hypothesized not to be v u l n e r a b i l i t y markers. Three s e l f - r e p o r t questionnaires were used: Automatic Thoughts Questionnaire (Hollon & Kendall, 1980), Hopelessness Scale (Beck et a l . , 1984), and the Dysfunctional Attitude Scale (Welssman, 1980; Welssman & Beck, 1978). Method Measures Automatic Thoughts Questionnaire. The Automatic Thought Questionnaire (ATQ; Hollon & Kendall, 1980; see Appendix M) is a self-report questionnaire which assesses the frequency of depression-related cognitions. Subjects are asked to rate on a 5-polnt scale how often they experienced 30 depression-related cognitions in the past week. Scores range from 30 to 150, with higher scores Indicative of higher frequency of depressive cognitions. Factor analysis of the ATQ has produced a four factor solution: personal maladjustment and desire for change (e.g., "What's wrong with me?"), negative self-concept and expectations (e.g., "My future is bleak"), low self-esteem (e.g., "I'm worthless"), and helplessness (e.g., "I can't f i n i s h anything") (Hollon & Kendall, 1980). These factors 119 are in concordance with the di s t o r t i o n s described by Beck et a l . ( 1 9 7 9 ) . The ATQ has demonstrated strong Internal r e l i a b i l i t y . Cronbach's alpha and the s p l i t - h a l f r e l i a b i l i t y c o e f f i c i e n t were reported as .87 or above, and . 9 6 , respectively (Dobson & Shaw, 1 9 8 6 ; Harrell & Ryon, 1 9 8 3 ; Hollon & Kendall, 1 9 8 0 ) . Test-retest r e l i a b i l i t y estimates are not available to date. In terms of v a l i d i t y , the ATQ has been found to discriminate between depressed and nondepressed students (Hollon & Kendall, 1 9 8 0 ) . This expected finding has been replicated with a c l i n i c a l sample (Dobson & Shaw, 1 9 8 6 ) . Likewise, a strong correlation has been found between the Beck Depression Inventory and the ATQ (r = . 62 to . 8 4 ; Dobson & Brei t e r , 1 9 8 3 ; Dobson & Shaw, 1 9 8 6 ) . Hopelessness Scale. The Hopelessness Scale (HS; Beck et a l . , 1 9 7 4 ; see Appendix N) is a 20-item true/false scale designed to r e f l e c t negative expectancies about the future. Most of the scale items were cul l e d from pessimistic statements made by psychiatric patients judged by c l i n i c i a n s as r e f l e c t i n g feelings of hopelessness. Psychometric data are available from Beck et a l . ( 1 9 7 4 ) . C o e f f i c i e n t alpha was reported as . 9 3 , suggesting strong i n t e r n a l consistency. Item-total correlations ranged from $39 to . 7 6 . Test-retest r e l i a b i l i t y was not reported. With respect to concurrent v a l i d i t y , Beck et a l . (1974) reported that the HS correlated highly with c l i n i c i a n s ' ratings of hopelessness, with reported c o r r e l a t i o n of .74 120 with a general practice medical sample, and .62 with a sample of attempted suicide.patients. In addition, the HS correlated ,62 with the pessimism item of the Beck Depression Inventory. Dysfunctional Attitude Scale. The Dysfunctional Attitude Scale (DAS; Weissman, 1980; Weissman & Beck, 1978; see Appendix 0) is a 40-item self-report scale. Based on Beck's (1967) theoret i c a l formulation of depression, the DAS contains a series of attitudes or b e l i e f s indicative of depressogenic assumptions. Respondents are asked to indicate the extent of their agreement with each statement on a 7-point scale, y i e l d i n g a range of scores from 40 to 280. Psychometric properties of the DAS are sati s f a c t o r y . Cronbach's alpha c o e f f i c i e n t s range from .80 to .91, suggesting a high l e v e l of internal consistency (Dobson & Brelter, 1983; Dobson & Shaw, 1986; Oliver & Baumgart, 1985). Moderate to good test-retest r e l i a b i l i t y c o e f f i c i e n t s are reported at .62 to .84 for 6 to 12 week intervals (Hamilton & Abramson, 1983; O'Hara, Rehm, and Campbell, 1982; Oliver & Baumgart, 1985; Risklnd, Beck, & Smucker, 1983; Weissman, 1978). The DAS is moderately related to measures of depression. Reported c o r r e l a t i o n c o e f f i c i e n t s between the DAS and the Beck Depression inventory range from .30 to .64 (Dobson & Breiter, 1983; Dobson & Shaw, 1986: Oliver & Baumgart, 1985). Note that the relationship is only a moderate one, suggesting that the 121 DAS Is somewhat related, but conceptually d i f f e r e n t , from measures of depression. Stronger relationships have been found with more conceptually similar measures, such as the Automatic Thoughts Questionnaire (r = .78; Dobson & Shaw, 1986) and the Measures of Distorted and Depressed cognitions (r = .62; Krantz & Hammen, 1979). Procedure Subjects were asked to f i l l out the s e l f - r e p o r t questionnaires, with the experimenter avai l a b l e to answer any procedural questions. Hypotheses (a) As consistently demonstrated in previous l i t e r a t u r e , currently depressed individuals were expected to report more depression-related cognitions than nondepressed individuals. (b) Cognitions that require elaborative processing are, in general, hypothesized not to be sensitive measures of v u l n e r a b i l i t y markers in depression. Remitted depressed subjects* responses on these self-report measures would be similar to that of nondepressed individuals. Results Analysis The dependent measures were scores obtained from the ATQ, HS, and DAS. Each was submitted to a between-groups (CDG, RDG, NDG) analysis of variance, summarized in Appendix P. The means are presented in Table 11. Table 11 Questionnaire Scores CDG RDG NDG Self-report questionnaires DAS M 168.00 120.25 102.75 ADM N. A. N. A. N. A. SD (51.93) (41.10) (24.48) ATQ M 110.55 49.90 35.35 ADM N. A. 46.59 38.66 SD (26.77) (20.24) (7.11) HS M 13.53 5.55 2.50 ADM N. A. 4.59 3.46 SD (1.27) (1.37) (1.23) Note . CDG = Currently depressed group. RDG = Remitted depressed group. NDG = Nondepressed group. ADM = Adjusted means res u l t i n g from the analysis of covariance. DAS = Dysfunctional Attitude Scale. ATQ = Automatic Thoughts Questionnaire HS = Hopelessness Scale. 123 DAS For the DAS data, there was, as expected, an overal l main eff e c t for groups ( F ( 2 , 5 7 ) = 13. 9 0 , p. < . 0 0 1 ) . Tukey comparisons suggested that the CDG scoring s i g n i f i c a n t l y higher than the other two groups: CDG vs. NDG: g ( 3 , 5 7 ) = 7.20, p_ < .01; CDG vs. RDG: g ( 3 , 5 7 ) = 5.29, p_ < .01. Also as expected, the RDG was not distinguishable from the NDG, g ( 3 , 57) = 1.93, p_ > .05. hm For the ATQ data, there was an overall s i g n i f i c a n t main e f f e c t , F ( 2 , 5 7 ) = 8 2 . 8 1 , p_ < .001, as expected. Tukey comparisons showed that the CDG had s i g n i f i c a n t l y higher scores than both the NDG, g ( 3 , 5 7 ) = 11.66, p_ < .01, and the RDG, g ( 3 , 57) = 8.43, p_ < .01. Furthermore, the RDG scored s l i g h t l y higher than the NDG, g ( 3 , 57) = 3.23, p_ < .10. HS The HS data pa r a l l e l e d the ATQ data. There was a s i g n i f i c a n t o v e r a l l e f f e c t , F ( 2 , 5 7 ) = 36.22, p_ < .001. Tukey comparisons showed the CDG scored s i g n i f i c a n t l y higher than the two other groups (CDG vs. RDG: g ( 3 , 57) = 11.6 6 , p_ < .01; CDG vs. NDG: g( 3, 57 ) = 8 . 43, p_ < . 0 1 ) . Furthermore, the RDG had s l i g h t l y higher scores than the NDG, g ( 3 , 5 7 ) = 3.23, p_ < .10 Contrary to predictions, the remitted depressed subjects were distinguishable from the nondepressed subjects ln terms of their responses on the ATQ and the HS at p_ l e v e l of .10. Could t h i s difference be due to e x i s t i n g group 124 differences in age and BDI scores? As a preliminary test, c o r r e l a t i o n a l analyses were conducted for the remitted and nondepressed subjects only. The analyses showed no correlations with age (age with HS: r = .03; age with ATQ: r = .08), but substantial correlations with BDI scores (BDI with HS: r = .66; BDI with ATQ: r = .74). Given the l a t t e r r e s u l t , an attempt was made to adjust for this difference between groups by an analysis of covariance using BDI scores as the covariate. The adjusted means from the analysis of covariance are presented in Table 11. The results of the covariance, presented in Tables 4 and 5 of Appendix P, show that group differences in both ATQ and HS scores disappeared: respectively, £(1,36) = 1.50, p_ > .10, F(l,37) = 1.46, p_ > .10. Summary Consistent with the f i r s t hypothesis, currently depressed subjects endorsed more depression-related cognitions than remitted depressed or nondepressed subjects. When covarying out the effects of BDI scores, remitted depressed subjects endorsed no more depression-related cognitions than nondepressed subjects, lending support to the second hypothesis that the cognitions, as assessed by th i s battery of questionnaires, are not sensitive measures of v u l n e r a b i l i t y markers to depression. Chapter 11: Follow-up Data One manifestation of depressive v u l n e r a b i l i t y is a greater likelihood to develop future depressive episodes. The issue of the e l i g i b i l i t y of the Time 1 measures of v u l n e r a b i l i t y markers was re-examined by ascertaining whether these measures were predictive of future depression status. It is noted that the prediction aspect of the thesis is considered to be exploratory. That i s , solutions from regression analyses based on such a small sample siz e may not cross-validate (Harris, 1975). The intent of t h i s aspect of the study was to measure the rate of recurrence of depressive symptoms, as assessed by the Beck Depression Inventory, 3 months after the i n i t i a l experimental session. Three months was chosen because research has shown a good p r o b a b i l i t y of 20-24% of relapse within 3 months of recovery (Belsher & Costello, 1988). Method Materials Beck Depression Inventory. Refer to the materials write-up In Subjects section. Procedure For the currently depressed subjects, the experimental session was conducted during their depressive episodes. Since the intent was to measure recurrence and not maintenance of depressive symptoms, It was necessary to wait for the a l l e v i a t i o n of these subjects' symptoms. Thus, currently depressed subjects were followed to the point of 126. remission, defined as their discharge from the hospital. The o r i g i n a l intent was to obtain an objective measure of the a l l e v i a t i o n of symptoms, such as scores from the BDI or the HRSD. However, this proved to be impossible, because these patients were often discharged with very l i t t l e notice. For these subjects, the BDIs were mailed out 3 months after their discharge. The psy c h i a t r i s t as well as the psychiatric nurses were alerted of the c r i t e r i a of remission, and Informed the experimenter of the patient's status. The time lag between the experimental session and the mailing of the BDIs was noted for each currently depressed subject, and was matched for both a remitted depressed and a nondepressed subject. Hypothes is (a) Measures of depressive automatic processing are predictive of future depressive symptoms. The predictive power of these measures goes beyond that of the self-report questionnaires and the i n i t i a l l e v e l s of depression. Results Analys is To determine which cognitive measures taken at Time 1 were predictive of relapse, as defined by BDI scores greater than 14, a hi e r a r c h i c a l regression analysis was conducted, using Time 2 BDI scores as the outcome variable. The predictor variables used in the regression analysis were: scores from the ATQ, HS, and DAS, composite scores (described in the data transformation section) from the 127 d i c h o t l c l i s t e n i n g , probe detection, and i m p l i c i t memory tasks, Time 1 BDI scores, and frequency of previous depressive episode. The la s t variable was Included because several studies have found that variable to be predictive of relapse (e.g., Dent & Teasdale, 1988 ). subjects who mailed the questionnaires Broken down by groups, the average time lag3 between the experimental session and the mailing of the follow-up A questionnaires were: CDG: M =8.29 months (SD = 2.61), RDG: M = 6.40 (SD = 2.67), NDG: M = 9.01 (SD = 3.15). Time 2 follow-up data, summarized ln Table 12, were collected on 54 of the 60 subjects. A l l subjects in both the remitted depressed and nondepressed groups completed the follow-up questionnaires, while 6 out of the 20 currently depressed subjects f a i l e d to return their questionnaires, even with a telephoned reminder. Using the cut-off score of 15 on the BDI, 0 of the 20 subjects in the NDG, 9 of the 20 remitted depressed subjects, and 10 of the 14 CDG subjects were c l a s s i f i e d as depressed at follow-up. Data Transformation Due to the multiple measures used in Time 1, an attempt was made to reduce the number of variables by computing composite measures based on the c r i t i c a l conditions. For the d i c h o t l c l i s t e n i n g task, a composite score was computed for each subject by subtracting the detection latencies associated with the positive words from those associated with the depression words. For the visual probe task, the 128 Table 12 Follov-up Beck Depression Inventory scores II Depressed"! II Nondepressed"2 CDG (n=14) M SD 29 . 25 (13.52) 4.33 (7.51) RDG (n=20) M SD 22. 33 (5.39) 6.18 (5.64) NDG (n=20) M SD N.A. 1.63 (3.10) Note. 1. Using the c r i t e r i o n of Beck Depression Inventory score >= 15. 2. Using the c r i t e r i o n of Beck Depression Inventory score < 15. CDG = Currently depressed group. RDG = Remitted depressed group. NDG = Nondepressed group. 129 c r i t i c a l t r i a l s were those where the stimulus words were presented ln the lower half of the screen followed by a probe presentation ln the lower half of the screen. On those t r i a l s , a composite score was made by subtracting the t r i a l s containing the positive words from those containing the depression words. F i n a l l y , for the i m p l i c i t memory task, a measure was computed from the difference of the production of the previously primed happiness words from that of the depression words. Missing data From a sample of 60, 50 data points were used in the regression analysis. Six subjects from the CDG f a i l e d to return t h e i r follow-up questionnaires. Four subjects from the CDG and RDG were assigned missing values In the frequency of previous depressive episode variable. In response to the inquiry of previous episodes, these subjects gave the response " a l l my l i f e " . Even when pressed to be more s p e c i f i c , these subjects were unable to give an e s t i m a t e 0£ the number Of previous episodes. Consequently, these subjects were given missing values on that variable. Regression Analysis Results The correlations between predictor and outcome variables are presented in Table 13, whereas correlation tables for the measures used ln thi s thesis are presented in Appendix Q. The hypothesis states that measures of automatic processing would be predictive beyond sel f - r e p o r t measures, 130 Table 13 Correlations between Predictor Variables with Beck  Depression Inventory scores BDI-Tlme 1 BDI-Tlme 2 BDI-Tlme 1 1.00 .77 ATQ .91 .76 HS .74 .62 DAS .46 .36 Dichotlc l i s t e n i n g task .14 .14 Visual probe task .37 .14 Implicit memory task .01 .03 Frequency of previous episodes of depression .42 .67 Note. BDI-Tlme 1 = Beck Depression Inventory score at Time 1. BDI-Tlme 2 = Beck Depression inventory score at Time 2. ATQ = Automatic Thoughts Questionnaire. HS = Hopelessness Scale. DAS = Dysfunctional Attitude Scale. 131 I n i t i a l BDI scores, and previous episodes of depression. To test t h i s , the sel f - r e p o r t measures, Time 1 BDI scores, and number of previous episodes were entered at Step 1 of the regression analysis. The measures of automatic processing were entered at Step 2. Step 1 variables s i g n i f i c a n t l y predicted Time 2 BDI scores (Multiple R = .86, Adjusted R-squared= .74, F(5,44) = 24.51, p_ < .05). The inclusion of the measures of automatic measures did not add to the prediction analysis (Multiple R = .86, Adjusted R-squared = .74). An additional regression analysis was conducted to rep l i c a t e previous findings that i n i t i a l BDI scores and history of depression are predictive of future dysphoria l e v e l s . A regression analysis was conducted that allowed the control of the order of entry of the variables. Using Time 1 BDI scores as the f i r s t variable entered into the regression analysis produced a multiple R of .76, Adjusted R-squared = .56, F(l,48) = 37.30, p. < .001. The addition of the frequency of previous episodes further contributed to the regression analysis: Multiple R = .88, adjusted R-squared = .72, F(2, 47) = 16.92, p_ < .01. Summary Contrary to predictions, responses on the tasks assessing automatic measures were not predictive of future depression status. Indeed, these measures correlated poorly with Time 2 BDI scores: r = .03 to .14. It was possible to predict future levels of dysphoria, with much of the variance accounted for (adjusted R-squared = .68 and .12), with i n i t i a l depression levels along with the history of previous episodes of depression. 133 Chapter 12: Discussion Summary of Findings The aim of this thesis was to find support for cognitive v u l n e r a b i l i t y factors In automatic processing of depression-related Information. Four main hypotheses were examined: (a) Currently depressed Individuals would show a bias for the depression-related stimuli on the automatic tasks; (b) remitted depressed individuals' pattern of performance on the automatic tasks would resemble that of the currently depressed individuals; (c) remitted depressed ind i v i d u a l s ' pattern of performance on the e f f o r t f u l tasks would resemble that of the nondepressed individuals; and (d) data from the automatic tasks would be predictive of future depressive symptoms. The f i r s t hypothesis was only p a r t i a l l y supported in the i m p l i c i t memory task. S p e c i f i c a l l y , the remitted depressed subjects, compared to the nondepressed subjects, showed a greater priming e f f e c t for the depression-content s t i m u l i . Unfortunately, this depressive bias was not obtained for the currently depressed subjects, contrary to the f i r s t hypothesis, a depressive bias was not observed in the d i c h o t l c l i s t e n i n g and the probe detection tasks. Rather, both groups of depressed subjects showed an even-handedness in their processing across the d i f f e r e n t content conditions. However, the nondepressed subjects showed a bias for the positive s t i m u l i . In the dichotlc l i s t e n i n g task, these subjects had shorter detection latencies when the positive s t i m u l i , compared to the depression-related s t i m u l i , were presented in the unattended channel. F i n a l l y , the probe detection task was an insensitive measure of depressed-nondepressed differences. The second hypothesis was examined only for the two tasks that were sensitive to depressed-nondepressed differences. This hypothesis was o n l y , p a r t l a l l y supported. In the dic h o t i c l i s t e n i n g task, the remitted depressed subjects' pattern of performance was similar to that of the currently depressed individuals. Although the results from the i m p l i c i t memory task suggested that the remitted depressed subjects showed more priming for the depression-content words than the nondepressed subjects, this depressive bias was not found for the currently depressed subjects. r The t h i r d hypothesis was supported. When the effects of Beck Depression Inventory scores were covaried out, remitted depressed: subjects endorsed no more depression-related cognitions than the nondepressed subjects. F i n a l l y , the fourth hypothesis was not supported. The automatic measures were found not to be predictive of relapse of depressive symptoms. The apparent discrepancy between the second and fourth hypotheses can be resolved with the view that depressive automatic processes are "scars" (Lewinsohn et a l . , 1981) from having experienced a depressive episode. However, they are not v u l n e r a b i l i t y f a c t o r s i n that they do not serve as a 135 predisposition to future depression. However, the I n a b i l i t y of this study to predict depressive symptoms does not necessarily rule out the p o s s i b i l i t y that depressive automatic processes are v u l n e r a b i l i t y factors. Teasdale (1988) argued that the onset of depressive symptoms is not of primary importance. More central to the issue of v u l n e r a b i l i t y is the study of the persistence and exacerbation of these depressive symptoms. It would be of Interest to have continued to follow these subjects to determine whether the automatic measures are predictive of the c h r o n l c i t y and severity of the depressive symptoms. Potential Limitations of Work Before discussing the implications of this work, some of i t s limitations are addressed. The f i r s t area addresses s t a t i s t i c a l considerations. One may argue that the f a i l u r e of the predicted Fs to reach significance in the probe detection was due to the lack of power since a r e l a t i v e l y small sample size (n = 20) was used. However, this is not l i k e l y to be the case since the same sample size was used for the dichotlc l i s t e n i n g task, but was s u f f i c i e n t for that task to show s i g n i f i c a n t r e s u l t s . One may argue that differences in the results between the tasks assessing automatic and e f f o r t f u l processes may l i e ln the s t a t i s t i c a l analyses conducted. In p a r t i c u l a r , the analysis of covariance was applied to the Hopelessness Scale and the Automatic Thoughts Questionnaire, but was not applied to any of the tasks assessing automatic processes. 136 As Kirk (1982) noted, one condition for an analysis of covariance i s an adequate magnitude of correlation between the covariate and the dependent variables. Such an analysis was warranted in the cases of the Hopelessness Scale and the Automatic Thoughts Questionnaire, because correlations between these and the Beck Depression i n v e n t o r y scores were s u f f i c i e n t l y high (.91 and .74, respectively), but was not warranted for the automatic measures because these measures were very much less correlated with Beck Depression Inventory scores (r = .01 to .37). The p o s s i b i l i t y exists that the pattern of results obtained may be r e f l e c t i n g the c h a r a c t e r i s t i c s of the subjects groups. The central hypothesis in this thesis is that the two depressed groups d i f f e r from the nondepressed group on their processing s t y l e . That difference may be accounted for by the difference in the medication status of the groups. That i s , a l l subjects in the currently depressed group and 8 of the 20 remitted depressed subjects were on antidepressants. Presumably, none of the nondepressed subjects were on antidepressants. Thus, the effects of antidepressants may be a confounding factor. Another l i m i t a t i o n of this study is i t s f a i l u r e to s p e c i f i c a l l y address whether automatic processing bias is s p e c i f i c to depressive disorders. The absence of a general psychiatric control group means that one cannot rule out that the obtained effects are due to general psychopathology, rather than to depression per se. 137 This r e s e a r c h assessed automatic and e f f o r t f u l processing by a limited number of tasks. As such, these results are limited to attentive, i m p l i c i t memorial, and s e l f - r e p o r t biases. Certainly, future research addressing automatic processes as measures of v u l n e r a b i l i t y markers needs to use other tasks which assess automatic processes. Potential Contributions of the Study Despite these limitations, t h i s research contains potential contributions to the cognitive v u l n e r a b i l i t y f i e l d . This research may offer a refinement to schema theory ln at least two ways. F i r s t , the ex i s t i n g l i t e r a t u r e examining schematic processes as v u l n e r a b i l i t y markers, on the whole, has yielded l i t t l e support. This l i t e r a t u r e has used, for the most part, tasks requiring e f f o r t f u l processes. However, the results from t h i s research suggest that the d i s t i n c t i o n between automatic and e f f o r t f u l processes in unipolar depression is v a l i d , and that automatic but not e f f o r t f u l processes may be v u l n e r a b i l i t y markers. If schemata are seen as v u l n e r a b i l i t y markers, then perhaps schemata should be reconceptualized as involving only automatic processes. Second, schema theory and past research suggest that depressed vulnerable Individuals are characterized by a depressive bias. In the attentional tasks of the dichotlc l i s t e n i n g task, a depressive bias was not found for the two depressed groups. Rather, what distinguished the depressed groups from the nondepressed group was the lack of positive 138 bias. It is noted that previous research which found a depressive bias used tasks which tapped into e f f o r t f u l processes. Together, these results suggest an ordering of type of biases according to cognitive processes. In p a r t i c u l a r , i t is suggested that depressive attentive processes are characterized by a lack of positive bias while e f f o r t f u l processes (memorial processes, reporting of cognitions) are characterized by a depressive bias. I now adopt the assumption that automatic processes involve the early stages or processing, whereas the e f f o r t f u l processes involve the later stages (Kahneman, 1973). For example, one needs to attend to an Item before one can r e c a l l i t . So i t appears that at the early stages of processing, a depressed individual processes stimuli without a positive bias. But at the later stages of e f f o r t f u l processing, where the depressed individual is allowed to elaborate and integrate the information, a depressive bias develops. This pattern raises the p o s s i b i l i t y that a positive bias in the early stages of processing somehow serves to prevent the construing of Information in a depressogenic manner. In terms of methodological issues, t h i s research points to the need of using more than one method of assessing v u l n e r a b i l i t y . This research shoved that sometimes measures of v u l n e r a b i l i t y do not correspond, s p e c i f i c a l l y , evidence of cognitive v u l n e r a b i l i t y was found in depressive-style processing in remitted depressed individuals, but t h i s may not be predictive of relapse. This lack of correspondence 139 may suggest that the nature of cognitive v u l n e r a b i l i t y is complex and multifaceted. That i s , markers of vulnerable individuals may not be predictive of relapse, and what is predictive of relapse may not be predictive of the onset of a depressive episode, and so forth. To tease out some of these potential relationships, research examining cognitive v u l n e r a b i l i t y needs to include more that one method of measuring v u l n e r a b i l i t y . This research might p o t e n t i a l l y have c l i n i c a l -Implications. T r a d i t i o n a l l y , the outcome of therapy has been based s o l e l y on patients' subjective reports of wellness and the absence of symptoms. The results of this thesis suggest that despite their subjective sense, an ongoing v u l n e r a b i l i t y - not necessarily subject to conscious awareness - may s t i l l p e r sist. If l e f t unchecked, these individuals may be very l i k e l y to relapse at some future time. It may be possible that some experimental cognitive automatic tasks may be used to i d e n t i f y individuals who seem well but, nevertheless, require further treatment (Williams et a l . , 1988) . F i n a l l y , t h i s i n i t i a l support for depressive automatic process argues for ongoing Investigations in cognitive processes ln depression. 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Toronto: Wiley. Zung, W. W. K. (1969). A cross-cultural survey of symptoms of depression. American Journal of Psychiatry, 126, 154-159. Zuroff, D. C , Colussy, S. A., & Wieglus, M. S. ( 1 9 8 3 ) . Selective memory and depression: A cautionary note concerning response bias. Cognitive Therapy and  Research, 7, 223-232. Appendix A Schedule for Affective Disorders and Schizophrenia 159 Assessment of psychiatric history Fine. Now I would l i k e to ask you some questions about your past. As before, these questions are a standard set of questions that I ask everybody. The questions w i l l cover some of the kinds of problems or d i f f i c u l t i e s that many people have at some time during their l i v e s . Some of the questions may not be applicable, but i t is important to ask them of everybody. 1. Were you ever a patient In a psychiatric hospital or ward? If yes, Whom did you see? What kinds of problems were you having then? 2. Have you ever seen anyone for emotional problems, your nerves, or the way you were feeling or acting? If yes, Whom did you see? What kinds o£ problems were you having then? 3. were there any times when you or someone else f e l t that you needed help because of your feelings, your nerves, or the way you were acting? If yes, What kinds of problems were you having then? i 1 6 0 Assessment of history o£ depression Now, think of the worst week of your l i f e , the lowest point in your l i f e . Have you got a week in mind? During t h i s most severe period, 1. Were you bothered by fee l i n g depressed, sad, blue, hopeless, or down ln the dumps? Did those feelings l a s t more than one week? How about more than two weeks? During that period, were you bothered by feelings that you didn't care anymore, or didn't enjoy anything? Did those feelings l a s t more than one week? How about more than two weeks? What about feeling i r r i t a b l e or e a s i l y annoyed? 2. During that time did you seek help from anyone l i k e a doctor, or minister or even a friend, or did anyone suggest that you seek help? Did you take any medication? Did you act d i f f e r e n t l y with people, your family, at work, or at school? 3. During the most severe period were you bothered by .... poor appetite or weight loss, or Increased appetite or weight gain? trouble sleeping or sleeping too much? loss of energy, e a s i l y fatigued, or feeling tired? loss of interest or pleasure in your usual a c t i v i t i e s or in sex? fe e l i n g g u i l t y or down on yourself? trouble concentrating, thinking, or making decision? thinking about death or suicide? (Did you attempt suicide?) being unable to s i t s t i l l and have to keep moving or the opposite - feeling slowed down and have trouble moving? Did anything cause the depression? (Do not include i f due to uncomplicated bereavement. Guidelines for defining "uncomplicated bereavement": - the depressive syndrome did not l a s t more than six months - there was no suicide attempt nor great s u i c i d a l preoccupation or talk (some Ideation is common) - no ho s p i t a l i z a t i o n - no marked retardation - no morbid preoccupation with g u i l t or self-worth How long did the depression la s t ? How many episode l i k e this have you had? If unable to give exact number: Would you say that you have had at least d i f f e r e n t episodes l i k e that? 162 Assessment for episodes of mania. 1. Did you ever have a period when you f e l t extremely good or high - c l e a r l y d i f f e r e n t from your normal s e l f ? Did f r i e n d s or your f a m i l y think than t h i s was more than j u s t f e e l i n g good? Did i t l a s t a t l e a s t one week? Were these t h i n g s under the i n f l u e n c e of drugs or a l c o h o l ? (Do not include If a p p a r e n t l y under the i n f l u e n c e of drugs or a l c o h o l i n t o x i c a t i o n ) 2. (At l e a s t three symptoms present to meet DSM-IIIR c r i t e r i a . ) During the most severe p e r i o d were you more a c t i v e than usual - e i t h e r s o c i a l l y , at work, s e x u a l l y , or p h y s i c a l l y a c t i v e ? were you more t a l k a t i v e than usual or f e l t a pressure to keep on t a l k i n g ? d i d your thoughts race or d i d you t a l k so f a s t t h at i t was d i f f i c u l t f o r people to f o l l o w what you were saying? d i d you f e e l you were a very Important person, had s p e c i a l p l a n s , powers, t a l e n t s , or a b i l i t i e s ? d i d you need i e s s s l e e p than usual? d i d you have t r o u b l e c o n c e n t r a t i n g on what was going on because your a t t e n t i o n kept jumping to unimportant t h i n g s about you? d i d you do anything f o o l i s h t h a t c o u l d have gotten you i n t o a l o t of t r o u b l e , l i k e buying t h i n g s , business investments, sexual I n d i s c r e t i o n s , r e c k l e s s d r i v i n g ? 3. (symptoms were so severe that meaningful c o n v e r s a t i o n was impossible, there was s e r i o u s Impairment In f u n c t i o n i n g , or he was h o s p i t a l i z e d . ) Were you h o s p i t a l i z e d ? Were you so e x c i t e d that I t was almost impossible to hold a c o n v e r s a t i o n with you? Did i t cause t r o u b l e s with people, with your f a m i l y , your work, or other usual a c t i v i t i e s ? 163 Determining any evidence of a thought disorder. Has there been a time when you heard voices or other sounds that other people couldn't hear? Have you ever had visions or see things that were not v i s i b l e to other people? What about strange smells or strange feelings in your body? Has there been a time when you had b e l i e f s or ideas that you later found out were not true l i k e people being out to get you, or talking about you behind your back? Have you ever c a l l attention to yourself - l i k e dressing ln some odd way or doing something strange? Have people ever had trouble understanding what you were saying because your speech was mixed up, or because you didn't make sense In the way you were talking? Inquiring for possible organic cause: During that time -were you drinking a l o t or had just stopped? were you taking any drugs - l i k e LSD, speed? were you physically i l l then? 165 Appendix B Hamilton Rating Scale f o r Depression Hamilton Rating Bcale f o r Depression DEPRESSED MOOD: sadness, hopeless, helplessness, vorthlessness 0 Absent 1 These feeling states Indicated only on questioning 2 These fe e l i n g states spontaneously reported v e r b a l l y 3 Communicates fee l i n g states non-verbally - i . e . , through f a c i a l expression, posture, voice, and tendency to weep 4 Patient reports VIRTUALLY ONLY these f e e l i n g states in his spontaneous verbal and non-verbal communication. FEELINGS OF GUILT 0 Absent 1 Self-reproach, feels he has l e t people down 2 Ideas of g u i l t or rumination over past errors or s i n f u l deeds. * 3 Present Illness Is a punishment. Delusions of g u i l t . 4 Hears accusatory or denouciatory voices and/or experiences threatening v i s u a l hallucinations. SUICIDE 0 Absent 1 Feels l i f e Is not worth l i v i n g 2 Wishes he were dead or any thoughts of possible death to s e l f 3 Suicide ideas or gesture 4 Attempts at suicide (any serious attempts rates 4) INSOMNIA EARLY 0 No d i f f i c u l t y f a l l i n g asleep 1 Complains of occasional d i f f i c u l t y f a l l i n g asleep i . e . , more than 1/2 hour 2 Complains of nightly d i f f i c u l t y f a l l i n g asleep INSOMNIA MIDDLE 0 No d i f f i c u l t y 1 Patient complains of being r e s t l e s s and disturbed during the night 2 Waking during the night - any getting out of bed 167 r a t e s 2 (except f o r purposes of v o i d i n g ) 6. INSOMNIA LATE 0 No d i f f i c u l t y 1 Waking i n e a r l y hours of the morning but goes back to s l e e p 2 Unable to f a l l a s l e e p again i f gets out of bed. 7. WORK AND A C T I V I T I E S 0 No d i f f i c u l t y 1 Thoughts and f e e l i n g s of i n c a p a c i t y , f a t i g u e , or weakness r e l a t e d to a c t i v i t i e s , work, or hobbies 2 Loss of i n t e r e s t i n a c t i v i t y , hobbies, or work -e i t h e r d i r e c t l y reported by p a t i e n t , or i n d i r e c t l y i n l i s t l e s s n e s s , I n d e c i s i o n , and v a c i l l a t i o n ( f e e l s he has to push himself to work or a c t i v i t i e s ) 3 Decrease In a c t u a l time spent i n a c t i v i t i e s or decrease i n p r o d u c t i v i t y . In h o s p i t a l , r a t e 3 i f p a t i e n t does not spend at l e a s t three hours a day i n a c t i v i t i e s ( h o s p i t a l job or hobbles) e x c l u s i v e of ward chores 4 stopped working because of present I l l n e s s . In h o s p i t a l , r a t e 4 If p a t i e n t engages i n no a c t i v i t i e s except ward chores, or I f p a t i e n t f a i l s to perform ward chores u n a s s i s t e d 8, RETARDATION: slowness of thought and speech; impaired a b i l i t y to concentrate; decreased motor a c t i v i t y Normal speech and thought S l i g h t r e t a r d a t i o n at i n t e r v i e w Obvious r e t a r d a t i o n at i n t e r v i e w Interview d i f f i c u l t Complete stupor 9. AGITATION 0 None 1 " P l a y i n g w i th" hands, h a i r , e t c . 2 Hand-wringing, n a i l - b i t i n g , h a l r - p u l l i n g , b i t i n g of l i p s 10. ANXIETY PSYCHIC 0 No d i f f i c u l t y 1 S u b j e c t i v e t e n s i o n and i r r i t a b i l i t y 2 Worrying about minor matters 3 Apprehensive a t t i t u d e apparent i n face or speech 0 1 2 3 4 168 4 Fears expressed without q u e s t i o n i n g ANXIETY SOMATIC P h y s i o l o g i c a l concomitants of a n x i e t y , such as: G a s t r o - i n t e s t i n a l - d r y mouth, wind, i n d i g e s t i o n , d i a r r h e a , cramps, b e l c h i n g , C a r d l o - v a s c u l a r - p a l p i t a t i o n s , headaches R e s p i r a t o r y - h y p e r v e n t i l a t i o n , s i g h i n g U r i n a r y frequency Sweating 0 Absent 1 M i l d 2 Moderate 3 Severe 4 I n c a p a c i t a t i n g SOMATIC SYMPTOMS GASTRO-INTESTINAL 0 None 1 Loss of a p p e t i t e but e a t i n g without s t a f f encouragement. Heavy f e e l i n g s i n abdomen 2 D i f f i c u l t y e a t i n g without s t a f f u r g i n g . Requests or r e q u i r e s l a x a t i v e s or medication f o r bowels or medication f o r g a s t r o - l n t e s t i n a l symptoms. SOMATIC SYMPTOMS GENERAL 0 None 1 Heaviness i n limbs, back, or head. Backaches, headaches, or muscle aches. Loss of energy and f a t i g u a b i l l t y 2 Any c l e a r - c u t symptom r a t e s 2 GENITAL SYMPTOMS Symptoms such as: l o s s of l i b i d o menstrual d i s t u r b a n c e s 0 Absent 1 M i l d 2 Severe 3 Not a s c e r t a i n e d HYPOCHONDRIASIS 0 Not present 1 S e l f - a b s o r p t i o n ( b o d i l y ) 2 Preoccupation with h e a l t h 3 Frequent complaints, requests f o r help, e t c . 169 4 Hypochondrleal d e l u s i o n s 16. LOSS OF WEIGHT Rate e i t h e r A or B A. WHEN RATING BY HISTORY: 0 No weight l o s s 1 Probable weight l o s s a s s o c i a t e d with present i l l n e s s 2 D e f i n i t e (according to p a t i e n t ) weight l o s s B. ON WEEKLY RATINGS BY WARD PSYCHIATRIST, WHEN ACTUAL WEIGHT CHANGES ARE MEASURED 0 Less than 1 pound weight l o s s i n week 1 Greater than 1 pound weight l o s s In week 2 Greater than 2 pounds weight l o s s i n week 17. INSIGHT 0 Acknowledges being depressed and i l l 1 Acknowledges i l l n e s s but a t t r i b u t e s cause to bad food, c l i m a t e , overwork, v i r u s , need f o r r e s t , e t c . 2 Denies being i l l a t a l l 18. DIURNAL VARIATION Rate both A and B, but add 18B on l y i n t o t o t a l score A. Note whether symptoms are worse In morning or evening. I f NO d i u r n a l v a r i a t i o n , mark none. 0 No v a r i a t i o n 1 worse i n morning 2 worse i n evening B. When present, mark the s e v e r i t y of the v a r i a t i o n . Mark "none" i f NO v a r i a t i o n 0 None 1 M i l d 2 Severe 19. DEPERSONALIZATION AND DEREALIZATION Such as f e e l i n g s of u n r e a l i t y , n i h i l i s t i c ideas 0 Absent 1 M i l d 2 Moderate 170 3 Severe 4 Incapacitating 20. PARANOID SYMPTOMS 0 None 1 Suspicious (doubtful or t r i v i a l ) 2 More severe suspiciousness (e.g. others wish him harm) 3 Ideas of reference 4 Delusions of reference and persecution 21. OBSESSIONAL AND COMPULSIVE SYMPTOMS 0 Absent 1 Mild 2 Severe 22. HELPLESSNESS 0 Not present 1 Subjective feelings which are e l i c i t e d only by inquiry 2 Patient volunteers his helpless feelings 3 Requires urging, guidance and reassurance to accomplish ward chores or personal hygiene 4 Requires physical assistance for dress, grooming, eating, bedside tasks, or personal hygiene 23. HOPELESSNESS 0 Not present 1 Intermittently doubts that "things w i l l improve" but can be reassured 2 Consistently feels "hopeless" but accepts reassurances 3 Expresses feelings of discouragement, despair, pessimism about future, which cannot be dispe l l e d 4 Spontaneously and inappropriately perseverates, " I ' l l never get well" or i t s equivalent 24. WORTHLESSNESS: Ranges from mild loss of esteem, feelings of i n f e r i o r i t y , s e l f - d e p r e c i a t i o n to delusional notions of worthlessness 0 Not present 1 Indicates feelings of worthlessness (loss of self-esteem) only on questioning 2 Spontaneously indicates feelings of worthlessness (loss of self-esteem) 171 3 Different from 2 by degree. Patient volunteers that he is "no good", " i n f e r i o r " , etc. 4 Delusional notions of vorthlessness - e.g., "I am a heap of garbage" or i t s equivalent. Appendix C Interview probes for the Hamilton Rating Scale for Depression 173 interview probes for the Hamilton Rating Scale (Based on Klerman, Welssman, Rounsavllle, and Chevron (1984)). Item 1: How have you been feeling? Can you describe what your mood has been? Have you f e l t blue, down In the dumps, depressed? How bad has It been? Have you wanted to cry? Does crying help? Have you f e l t that you would l i k e to cry but that you were beyond tears? Have you f e l t hopeless, unable to control what happens to you, at the mercy of others or unable to do anything for yourself? How have you f e l t about the future? Can you see yourself getting better? Item 2: Have you blamed yourself for things you have done? Have you been down on yourself? Do you think that you are a bad person? Have you f e l t that you have l e t your friends and family down? Do you fee l g u i l t y about i t ? Have you f e l t that you are to blame for your i l l n e s s ? In what way? Do you think about sin? Item 3: Do you think much about death l a t e l y ? Have you f e l t that l i f e was not worth l i v i n g ? Have you wished that you were dead? Have you had any thoughts of taking your l i f e ? Have you made any plans to do so? Have you started to do things to work out that plan? Have you ac t u a l l y made an attempt on your l i f e ? Item 4: How have you been sleeping l a t e l y ? Any d i f f i c u l t i e s getting to sleep? How often? How long does i t take you to f a l l asleep? Item 5; Once you f a l l asleep, do you sleep through the night? Are you r e s t l e s s , keep waking up? (If gets up, make sure that 174 i t i s f o r another reason besides v o i d i n g ) Do you get up out of bed? Item 6: Do you wake e a r l y i n the morning? Stay awake or f a l l back to s l e e p . Is t h i s e a r l i e r t h a t you would normally get up? Item 7: How have you been doing i n work, housework, hobbies, i n t e r e s t s and s o c i a l l i f e ? Is t h i s any d i f f e r e n t than what you used to do? Item 10: Have you been f e e l i n g nervous, anxious or f r i g h t e n e d ? Have you f e l t tense or found i t hard to r e l a x ? Have you been worrying about l i t t l e t h i n g s ? Have you have a f e e l i n g of dread, as though something t e r r i b l e were about to happen? Have you tended to become f e a r f u l l n any s p e c i a l s i t u a t i o n such as being alone at home, going out alone, being l n crowds, t r a v e l l i n g , h e i g h t s , e l e v a t o r ? Item 11: I am going to read o f f a l i s t of symptoms. I would l i k e to say yes or no whether you have any of the f o l l o w i n g . (Read o f f l i s t of symptoms. I f yes to any, ask about s e v e r i t y . ) Item 12: How has your a p p e t i t e been? Have you had a heavy f e e l i n g l n you stomach? Have you been e a t i n g ? Do you need encouragement from somebody e l s e before you w i l l eat? Item 13: Do you f e e l t i r e d e a s i l y ? A l l the time? Is It an e f f o r t to do anything? Do you spend a l o t of time i n bed? Asleep? Do you have any aches and pains? F e e l i n g s of heaviness? Item 14: I am going to ask you a few q u e s t i o n s about you sex l i f e . Have you l o s t i n t e r e s t i n the o p p o s i t e sex/ your spouse/ your p a r t n e r ? Have you had l e s s s e x u a l d r i v e than usual? (for women) Have you noticed any change in your menstrual cycle? Item 15: Do you think much about your health? Do you find yourself worrying about your health? A lot? Item 16: Have you l o s t weight since the trouble started? How much? Item 17: What would you say is the nature of your trouble? what caused i t ? Item 18: At what time of day do you feel best? Morning? Afternoon? Evening? At what time of day do you f e e l worst? Item 19: Have you had the feeling at a l l that everything was unreal, that you were unreal or that the world was distant, remote, strange, or changed? Item 20: Are you suspicious of other people? Do you think people ar tal k i n g about you or laughing behind your back? Item 21: Do you find unpleasant, frightening, or ridiculous thoughts or words come into your head and won't go away, even when you t r y to get r i d of them? Do you find you have to keep checking or repeating things you have already done? Do you have to do things in a special way, sp e c i a l order or a cert a i n number of times? Are you a f r a i d you might commit some t e r r i b l e act without wanting to? Appendix D Beck Depression Inventory 177 Beck i n v e n t o r y On t h i s q u e s t i o n n a i r e are groups of statements. Please read each group of statements c a r e f u l l y . Then pick out the one statement i n each group which best d e s c r i b e s the way you have been f e e l i n g the PAST WEEK INCLUDING TODAY. C i r c l e the number beside the statement you p i c k e d . I f s e v e r a l statements i n the group seem to a p p l y e q u a l l y w e l l , c i r c l e each one. Be sure to read a l l the s t a t e m e n t s i n each g roup before making your c h o i c e . 1 0 I do not f e e l sad, 1 I f e e l sad. 2 I am sad a l l the time and I can't snap out of i t . 3 I am so sad or unhappy t h a t I can't stand i t . 2 0 I am not p a r t i c u l a r l y discouraged about the f u t u r e . 1 I f e e l d iscouraged about the f u t u r e . 2 I f e e l l i k e nothing to look forward t o . 3 I f e e l t h a t the f u t u r e Is hopeless and t h a t t h i n g s cannot Improve. 3 0 I do not f e e l l i k e a f a i l u r e . 1 I f e e l t h a t I have f a i l e d more than the average person. 2 As I look back on my l i f e , a l l I can see Is a l o t of f a i l u r e s . 3 I f e e l I am a complete f a i l u r e as a person. 4 O l get as much s a t i s f a c t i o n out of t h i n g s as I used t o . 1 I don't enjoy t h i n g s the way I used t o . 2 I don't get r e a l s a t i s f a c t i o n out of anything any more. 3 I am d i s s a t i s f i e d or bored with e v e r y t h i n g . 5 0 1 don't f e e l p a r t i c u l a r l y g u i l t y . 1 I f e e l g u i l t y a good p a r t of the time. 2 I f e e l q u i t e g u i l t y most of the time. 3 I f e e l g u i l t y a l l of the time. 6 O l don't f e e l I am being punished. 1 I f e e l I may be punished. 2 I expect to be punished. 3 I f e e l I am being punished. 7 0 1 don't f e e l d i s a p p o i n t e d l n myself. 1 I am d i s a p p o i n t e d i n myself. 2 I am d i s g u s t e d with myself. 3 I hate myself. 8 0 1 I don't f e e l I am any worse than anybody e l s e . I am c r i t i c a l of myself f o r my weaknesses or 178 mistakes. 2 I blame myself a l l the time f o r my f a u l t s . 3 I blame myself f o r e v e r y t h i n g bad t h a t happens. 9 0 1 don't have any thoughts of k i l l i n g myself. 1 I have thoughts of k i l l i n g myself, but I would not c a r r y them out. 2 I would l i k e to k i l l myself. 3 I would k i l l myself i f I had the chance. 10 0 . 1 don't c r y any more than u s u a l . 1 I c r y more now than I used t o . 2 I c r y a l l the time now. 3 I used to be able to c r y , but now I can't c r y even though I want t o . 11 0 I am no more i r r i t a t e d now than I ever am. 1 I get annoyed or i r r i t a t e d more e a s i l y than I used t o . 2 I f e e l i r r i t a t e d a l l the time now. 3 I don't get i r r i t a t e d a t a l l by the t h i n g s t h a t used to I r r i t a t e me. 12 0 1 have not l o s t i n t e r e s t i n other people. 1 i am l e s s i n t e r e s t e d i n other people than I used to be. 2 I have l o s t most of my i n t e r e s t i n other people. 3 I have l o s t a l l my i n t e r e s t i n other people. 13 0 1 make d e c i s i o n s about as w e l l as I ever c o u l d . 1 I put o f f making d e c i s i o n s more than I used t o . 2 I have greater d i f f i c u l t y i n making d e c i s i o n s than b e f o r e . 3 I can't make d e c i s i o n s a t a l l anymore. 14 0 I don't f e e l I look any worse than I used t o . 1 I am worried than I am l o o k i n g o l d or u n a t t r a c t i v e . 2 I f e e l t h a t there are permanent changes i n my appearance that make me look u n a t t r a c t i v e . 3 I b e l i e v e that I look u g l y . 15 0 1 can work about as w e l l as before. 1 I t takes an e x t r a e f f o r t to get s t a r t e d a t doing something. 2 I have to push myself v e r y hard to do anything. 3 I can't do any work at a l l . 16 0 1 can s l e e p as w e l l as u s u a l . 1 I don't s l e e p as w e l l as I used t o . 2 I wake up 1-2 hours e a r l i e r than usual and f i n d i t hard to get back to s l e e p . 3 I wake up s e v e r a l hours e a r l i e r than I used to and cannot get back to s l e e p . 179 17 0 I don't get more t i r e d than usual. 1 I get t i r e d more e a s i l y than I used t o . 2 I get t i r e d from doing almost anything. 3 I am too t i r e d to do anything. 18 0 My a p p e t i t e i s no worse than us u a l . 1 My a p p e t i t e i s not as good as i t used to be. 2 My a p p e t i t e i s much worse now. 3 I have no a p p e t i t e at a l l anymore. 19 0 I haven't l o s t much weight, i f any, l a t e l y . 1 I have l o s t more than 5 pounds. 2 I have l o s t more than 10 pounds. 3 I have l o s t more than 15 pounds. I am purposely t r y i n g to lose weight by e a t i n g l e s s . Yes No 20 0 I am no more worried about my h e a l t h than u s u a l . 1 I am worried about p h y s i c a l problems such as aches and pains, or upset stomach, or c o n s t i p a t i o n 2 I am very worried about p h y s i c a l problems and I t ' s hard to think of much e l s e . 3 I am so worried about my p h y s i c a l problems t h a t I cannot think about anything e l s e . 21 0 I have not n o t i c e d any recent change i n my i n t e r e s t i n sex. 1 I am l e s s i n t e r e s t e d i n sex than I used to be. 2 I am much l e s s i n t e r e s t e d i n sex now. 3 I have l o s t I n t e r e s t i n sex completely. Appendix E DSM-III-R diagnoses for Major Depressive Episode and Dysthmia 181 C r i t e r i a for Major Depressive Episode or Dysthymla according to the Diagnostic and S t a t i s t i c a l Manual of Mental Disorder (3rd ed. - revised; American Psychiatric Association, 1987): Major Depressive Episode: A. At least five of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood, or (2) loss of Interest or pleasure. 1. depressed mood 2. diminished Interest or pleasure in a l l , or almost a l l , a c t i v i t i e s most of the day, nearly a l l day 3. s i g n i f i c a n t weight loss or weight gain when not d i e t i n g 4. insomnia or hyposomnia nearly every day 5. psychomotor retardation or agit a t i o n nearly every day 6. fatigue or loss of energy nearly every day 7. feelings of worthlessness or excessive or Inappropriate g u i l t 8. diminished a b i l i t y to think or concentrate, or indecisiveness, nearly every day B. 1. not due to an organic factor 2. not a normal reaction to the death of a loved one C. Absence of delusions or hallucinations D. Not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder (American Psychiatric Association, 1987, p. 128-129.) Dysthymla A. Depressed mood for most of the day, for at least two years. B. Presence, while depressed, of at least two of the following: 1. poor appetite or overeating 2. insomnia or hypersomnia 3. low energy or fatigue 4. low self-esteem 5. poor concentration or d i f f i c u l t y making decisions 6. feelings of hopelessness C. During a two-year period of the disturbance, never without the symptoms in A for more than two months at a time. D. No evidence of Major Depressive Episode during the f i r s t two years of the disturbance. E. Absence of Manic Episode or Hypomania Episode F. Not superimposed on a chronic psychotic disorder, such as Schizophrenia or Delusional Disorder. G. Not due to an o r g a n i c cause. (American P s y c h i a t r i c A s s o c i a t i o n , 1987, p. 136-137). Appendix F L i s t of medications for currently' depressed and remitted depressed groups 184 L i s t of psychiatric medications for currently depressed and  remitted depressed subjects Currently depressed subjects N o r t r i p t y l i n e Trazadone Desipramine Lorazepan Panit idine Atenolol Nitrong Serax H e l l a r i l Clonazepan Lithium Carbonate Prozac Fluoxetine Imipramlne Atovam MAO Inhibitor with L-troptophan . Loprax R i v o t r l l Phenelzine Medobouride Amitriptyllne Doxepin Remitted depressed subjects Phenelzene Imipramlne Clomipramine Lorazepan Desipramine Lithium Anafravll L o r i m i l 185 Appendix G consent forms 188 Appendix H Interview 189 i n t e r v i e w Subject number Date Interviewer I. Assessment of demographic Information. Now I would l i k e to ask you some general questions about yourself. 1. How old are you? 2. Are you working at present? What do you do? (or) Have you ever worked? What did you used to do? 3. Are you married or l i v i n g with somebody? 4. Do you have any children? 5. How far did you get in school? Did you receive any special training? Now I am going to ask you a standard set of questions. The questions w i l l cover some of the kinds of problems or d i f f i c u l t i e s that many people have at some time during their l i v e s . Some of the questions may not be applicable but i t is important to ask them of everybody. II. Assessment of current depression. Now I am going to ask you how you are fe e l i n g at present. (Administer Hamilton) II I . Assessment of psychiatric history (administer SADS here) Appendix I Stimuli for the dichotic l i s t e n i n g task 191 Table 1: S t o r l e 3  P r a c t i c e 3 t o r l e s The o l d man gathered h i s three g r a n d c h i l d r e n around. He planned to take them to the c i r c u s t o n i g h t . The c i r c u s s t a r t e d at 8:30 so they l e f t the house a t 6:30. They p i l e d i n the car and s t a r t e d out f o r the c i r c u s . When they a r r i v e d a t the c i r c u s , most of the t i c k e t s had been s o l d but they managed to buy t i c k e t s f o r themselves. Jane wanted to s t a r t her s p r i n g c l e a n i n g today. She c a l l e d i n her f a m i l y and assigned a l i s t of d u t i e s . Each member of the f a m i l y was assigned to a d i f f e r e n t room. Things t h a t were to be thrown out were placed on the porch. At the end of the day there was a huge p i l e of junk on the f r o n t lawn. Target s t o r i e s On Saturday morning, the weather was m i l d and sunny. A f t e r f i n i s h i n g h i s chores of washing the car and buying the weekly g r o c e r i e s , John decided to go f o r a b i c y c l e r i d e . He rode along the r i v e r path. I t s t a r t e d to r a i n , f i r s t s o f t l y , then g r a d u a l l y the r a i n s t a r t e d to f a l l more s t e a d i l y and more h e a v i l y u n t i l i t poured. John raced home. Jane was going to have e i g h t dinner guests t o n i g h t . She asked her husband to s e t up the d i n i n g room while she ran her e r r a n d s . She f i r s t went to the g r o c e r y s t o r e where she. bought a r o a s t , c a r r o t s , potatoes, and bread. She went to the c l e a n e r s to pick up her d r e s s . She then vent- hone and put the r o a s t i n the over. A f t e r being i n the house a l l day, the dog was f i n a l l y l e t out. He s n i f f e d the c o l d a i r and walked over to h i s water d i s h . He t r i e d to d r i n k from i t but the water was f r o z e n . He walked over to h i s l e a s h , put i t i n h i s mouth, and s c r a t c h e d at the door i n hopes of being taken f o r a walk. John's job i s to d e l i v e r newspapers, s i n c e i t was the end of the month, he a l s o had to c o l l e c t payments. F i r s t , John went to the bank to get s m a l l b i l l s so he could g i v e change to h i s customers. Next, he went home to get h i s r e c e i p t book and an envelope to put the money i n . He then s t a r t e d h i s paper r o u t e . 192 Table 2. Recognition task i n the channel that you were supposed to Ignore, t h e r e were some words presented on t h a t channel. Here i s a l i s t of words. Were any of these words on t h a t channel? I f you are unsure, take a guess. Try to be as accurate as you can but don't spend too much time on any one word. were these words on that channel? Y/N Y/N 1. weary 2. robust 3. l i v e l y 4. f o r l o r n 5. s o r r y 6. encouraged 7. eager 8. w i t t y 9. miserable 10. d e s p a i r i n g 11. d e s t i t u t e 12. amusing 13. r e l a x e d 14. s o c i a b l e 15. bleak 16. s u c c e s s f u l 17. f o r t u n a t e 18. gr ieved 19. gloomy 20. g u i l t y 21. s u i c i d a l 22. burdened 23. s a t i s f i e d 24. anguished 25. beaten 26. merry 27. r e f r e s h e d 28. bold 29 . downcast 30. c a r e f r e e 31. capable 32. gloomy 33. s h a t t e r e d 34. d e s e r t e d 35. contented 36. devastated 37. d e f i c i e n t 38. r e g r e t f u l 39. dynamic 40. j o v i a l 41. a p a t h e t i c 42. e n t e r t a i n i n g 43. respected 44. bubbly 45. abandoned 46. drained 47. p l a y f u l 48. a c h i e v i n g 49. a f f l i c t e d 50. c h e e r f u l 51. worthless 52. remorseful 53. d e l i g h t e d 54. j o y f u l 55. melancholy 56. t e a r f u l 57. g i g g l y 58. wretched 59. o p t i m i s t i c 60. outgoing 193 Appendix J Analyses o£ variance for the d i c h o t i c l i s t e n i n g task Table 1 ANOVA Summary Table for Detection Latencies Source of variation df Ms Between subjects Groups Subjects w.groups 2 57 Within subjects Content word 1 Group x content word 2 Content x subject w.group 57 130207.66 54715.50 1320.03 71502.06 17155.84 2.38 .08 4.17 * Note . p_ < .05 Table 2 ANOVA Summary Table for Shadowing Errors Source of variation df Ms Between subjects Groups 2 5.61 3.10 * Subjects w.groups 5 7 1.81 Within subjects Content word 1 .41 .20 Group x content word 2 .61 .30 Content x subject w.group 57 2.00 Note. * p. < .05 Table 3 ANOVA Summary Table for Recognition Performance source of va r i a t i o n df Ms F Between subjects Groups Subjects w.groups 2 57 77.60 4.14 * 18.74 Within subjects Response (hit/miss) 1 Group x Response 2 Response x subjects 57 w.groups 11.70 .72 . 84 14.01*** .86 Content Group x content 1 2 Content x subjects w.groups 57 16.54 1 5 40 76 2.87 .24 Response x content 1 Response x content x group 2 Response x content x 57 subject w.groups 11.70 .32 .87 13 . 50*** . 37 Note. *** p_ < .001 * p_ < .05 Appendix K Analysis of variance for the probe detection task 197 ANOVA summary table for detection latencies Source of variation df Ms Between subjects Groups Subjects w.groups 2 57 Within subjects Content word 2 Group x content word 4 Content x subject w.group 114 Word position 1 Group x word position 2 Word position x subjects 57 w.groups Content x word position 2 Group x content x word 4 position Content x word position x 114 subjects w.groups Probe position 1 Group x probe postion 2 Probe position x subjects 57 w.groups Content x word position 2 Group x word pos x content 4 Word pos x content x 114 subjects w.groups 528516.37 115257.25 6916.56 13587.33 9360.65 27380.00 19551.12 10343.79 12118.95 12055.41 7950.12 863478.27 55952.67 25003.81 42706.11 23444.04 12835.38 4.59 * .74 1.45 2.65 1,89 1.52 1. 52 34.53*** 2.24 3.33 + 1.83 Probe position x content 1 Group x probe x content 2 Probe x content x subjects 57 w.groups Content x word position x 2 probe position Group x content x word x 4 probe Content x word x probe x 114 subjects w.groups 17306.81 411.54 6628.36 1090.59 8530.46 7474.66 2.61 .06 .15 1.14 Note. * p_ < .05 *** p_ < .001 + p_ < .05 with Greenhbuse-Geisser correction Appendix L Analyses of variance for the iraplic memory task 9 199 Table 1 ANOVA Summary Table f o r I m p l i c i t Memory Performance Source of v a r i a t i o n df Ms Between s u b j e c t s Groups C o n d i t i o n (primed vs Group x c o n d i t i o n Subjects w.groups unprimed)1 2 54 3.95 33.49 2.09 1.82 2.17 18.41*** 1.15 Within s u b j e c t s Content word 3 Group x content word 6 Content x c o n d i t i o n 3 Content x c o n d i t i o n x group 6 Content x c o n d i t i o n x group 162 x s u b j e c t s w. groups 1.25 .28 2.59 2.15 .96 1.30 .29 2.69 + 2.24 + Note. *** p. < .001 + p_ < .05 with Greenhouse-Geisser c o r r e c t i o n s Table 2 ANOVA Summary Table f o r E x p l i c i t Memory Task Performance Source of v a r i a t i o n df Ms F Between s u b j e c t s Groups 2 .84 .30 Subjects w.groups 27 2.79 Within s u b j e c t s Content word 3 20.48 28.52+++ Group x content word 6 .63 .88 Content x s u b j e c t w.group 81 .72 Note. +++ p_ < .001 with Greenhouse-Geisser c o r r e c t i o n 200 Appendix M Automatic Thoughts Questionnaire 201 Automatic Thoughts Questionnaire Listed below are a variety of thoughts that pop into people's heads. Please read each thought and indicate how frequently, i f at a l l , the thought occurred to you over the  last day. Please read each item c a r e f u l l y and c i r c l e the appropriate answers on the answer sheet In the following fashion (1 = "not at a l l " , 2 = "sometimes", 3 = "moderately often", 4 = "often", and 5 = " a l l the time"). Response I terns 1 2 3 4 5 1) I f e e l l i k e I'm up against the world. 1 2 3 4 5 2) I'm no good. 1 2 3 4 5 3) Why can't I ever succeed? 1 2 3 4 5 4) No one understands me. 1 2 3 4 5 5) I've l e t people down. 1 2 3 4 5 6) I don't think I can go on. 1 2 3 4 5 7) I wish I were a better person. 1 2 3 4 5 8) I'm so weak. 1 2 3 4 5 9) My l i f e ' s not going the way I want i t to 1 2 3 4 5 10) I'm so disappointed in myself. 1 2 3 4 5 11) Nothing feels good anymore. 1 2 3 4 5 12) I can't stand t h i s anymore. 1 2 3 4 5 13) I can't get started. 1 2 3 4 5 14) What's wrong with me. 1 2 3 4 5 15) I wish I were somewhere else. 1 2 3 4 5 16) I can't get things together. 1 2 3 4 5 17) I hate myself. 1 2 3 4 5 18) I'm worthless. 1 2 3 4 5 19) Wish I could just disappear. 1 2 3 4 5 20) What's the matter with me? 1 2 3 4 5 21) I'ma loser. 1 2 3 4 5 22) My l i f e is a mess. 1 2 3 4 5 23) I'ma f a i l u r e . 1 2 3 4 5 24) I ' l l never make i t . 1 2 3 4 5 25) I f e e l so helpless. 1 2 3 4 5 26) Something has to change. 1 2 3 4 5 27) There must be something wrong with me. 1 2 3 4 5 28) My future is bleak. 1 2 3 4 5 29) It's just not worth i t . 1 2 3 4 5 30) I can't f i n i s h anything. 202 Appendix N Hopelessness Scale 203 This q u e s t i o n n a i r e c o n s i s t s o£ a l i s t o£ twenty statements. Please read the statements c a r e f u l l y one by one. If the statement d e s c r i b e s your a t t i t u d e f o r the past week,  i n c l u d i n g today, w r i t e down TRUE next to i t . I f the statement i s f a l s e f o r you, w r i t e FALSE next to I t . You may simply write T f o r TRUE and F f o r FALSE. Please be sure to read each sentence. 1. I look forward to the f u t u r e with hope and enthusiasm. 2. I might as w e l l give up because t h e r e ' s nothing I can do about making things b e t t e r f o r myself. 3. When t h i n g s are going badly, I am helped by knowing t h a t they can't s t a y that way f o r e v e r . 4. I can't imagine what my l i f e would be l i k e l n ten y e a r s . 5. I have enough time to accomplish the t h i n g s I most want to do. 6. In the f u t u r e I expect to succeed i n what concerns me most. 7. My f u t u r e seems dark to me. 8. I happen to be p a r t i c u l a r l y l u c k y and I expect to get more of the good t h i n g s i n l i f e than the average person. 9. I j u s t don't get the breaks, and t h e r e ' s no reason to b e l i e v e I w i l l i n the f u t u r e . 10. My past experiences have prepared me w e l l f o r my f u t u r e . 11. A l l I can see ahead of me Is unpleasantness r a t h e r than p l e a s a n t n e s s . 12. I don't expect to get what I r e a l l y want. 13. when I look ahead to the f u t u r e I expect I w i l l be happier t h a t I am now. 14. Things j u s t won't work out the way I want them t o . 15. I have g r e a t f a i t h i n the f u t u r e . 16. I never get what I want so I t ' s f o o l i s h to want ' a n y t h i n g . 204 17. It is very unlikely that I w i l l get any r e a l s a t i s f a c t i o n in the future. 18. The future seems vague and uncertain to me. 19. I can look forward to more good times than bad times. 20. There's no use in r e a l l y trying to get something I want because I probably won't get i t . 205 Appendix 0 D y s f u n c t i o n a l A t t i t u d e Scale 206 This inventory l i s t s d i f f e r e n t attitudes or b e l i e f s which people sometimes hold. Read each statement c a r e f u l l y and decide how much you agree or disagree with the statement. To decide whether a given attitude is t y p i c a l of your way of looking at things, simply keep in mind what you are l i k e MOST OF THE TIME. 1 . It i s d i f f i c u l t to be happy unless one Is good looking, I n t e l l i g e n t , r i c h , and creative. 2. Happiness is more a matter of my attitude towards myself than the way other people f e e l about me. 3 . People w i l l probably think less of me If I make a mistake. 4. If I do not do well a l l the time, people w i l l not respect me. 5. Taking even a small r i s k i s f o o l i s h because the loss is l i k e l y to be a disaster. 6. It i s possible to gain another person's respect without being e s p e c i a l l y talented at anything. 7 . I cannot be happy unless most people I know admire me. 8. If a person asks for help, It Is a sign of weakness. 9. If I do not do as well as other people, i t means I am an i n f e r i o r human being. 1 0 . If I f a i l at my work, then I am a f a i l u r e as a person. 1 1 . If you cannot do something well, there is l i t t l e point in doing i t at a l l . 1 3 . Making mistakes is fine because I can learn from them. 1 3 . If someone disagrees with me, i t probably indicates he does not l i k e me. 1 4 . If I f a i l partly, i t i s as bad as being a complete f a i l u r e . 1 5 . If other people know what you are r e a l l y l i k e , they w i l l think less of you. 1 6 . I am nothing i f a person I love doesn't love me. 1 7 . One can get pleasure from an a c t i v i t y regardless of the end r e s u l t . .-, 18. People should have a reasonable likelihood of success before undertaking anything. 19. My value as a person depends greatly on what others think of me. 20. If I don't set the highest standards for myself, I am l i k e l y to end up a second-rate person. 21. If I am to be a worthwhile person, I must be t r u l y outstanding in at least one major respect. 22. People who have good ideas are more worthy than others who do not. 23. I should be upset i f I make a mistake. 24. My own opinions of myself are more Important than other's opinions of me. 25. To be a good, moral, worthwhile person, I must help everyone who needs It. 26. If I ask a question, i t makes me look i n f e r i o r . 27. It Is awful to be disapproved of by people Important to you. 28. "If you don't have other people to lean on, you are bound to be sad. 29. I can reach Important goal without slave driving myself. 30. It i s possible for a person to be scolded and not get upset. 31. I cannot trust other people because they might be cruel to me. 32. If others d i s l i k e you, you cannot be happy. 33. It i s best to give up your own interests in order to please other people. 34. My happiness depends more on other people that i t does on me. 35. I do not need the approval of other people in order to be happy. 36. If a person avoids problems, the problems tend to go .;, 3 7 . I can be happy even i£ I miss out on many o£ the good things in l i f e . 3 8 . What other people think about me Is very Important. 3 9 . Being Isolated from others is bound to lead to unhappiness. 40. I can find happiness without being loved by another person. 209 Appendix P Analyses of Variance and Covariance f o r the S e l f - r e p o r t Q u e s t i o n n a i r e s 210 Table 1 ANOVA Summary Table for the DAS Source of v a r i a t i o n df MS F Between subjects Subjects w.groups 1 57 22812. 1641. 92 29 13. 9 0 * * * Note. *** D < .001 Table 2 ANOVA Summary Table for the HS Source of v a r i a t i o n df MS F Between subjects Subjects w.groups 1 57 645. 17. 02 81 36. 2 2 * * * Note. *** p_ < .001 Table 3 ANOVA Summary Table for the ATQ Source of v a r i a t i o n df Ms F Between subjects 1 31817 .22 82.81*** Subjects w.groups 57 384 .23 Note. *** p. < .001 Table 4 Analysis of Covariance for HS Source of variation df Ms F Between subjects Subjects w.groups 1 37 9.47 6.47 1.46 Table 5 Analysis of Covariance for ATQ Source of var i a t i o n d i MS F Between subjects Subjects w.groups 1 37 191.68 128.99 1.50 212 Appendix Q Correlation Tables of Measures by Group 213 Table 1 Correlations of Measures for the Currently Depressed Group SES FREQ B2 DL PD IM Bl ATQ HS DAS AGE ED B2 1.0 DL .15 1.0 PD .01 .24 1.0 IM -.29 .15 -.14 1.0 Bl .75 .38 -.11 .12 1.0 ATQ .66 .14 -.14 .00 .74 1.0 HS .30 -.18 -.18 .21 .48 .70 1.0 DAS .30 -.11 .19 .14 .30 .34 .62 1.0 AGE .34 -.25 -.07- .11 .28 .21 .07 -.17 1.0 ED - .17 -.17 -.07- .17--.12 -.14 .00 .19 -.02 1.0 SES .31 .43 .22- .24 .25 .26--.01 -.05 -.41 -.79 FREQ .50 -.35 .16- .01 . 25 . 36 .45 .39 -.02 -.14 1.0 .19 1.0 Table 2 Correlations of Measures for the Remitted Depressed Group B2 DL PD IM B l ATQ HS DAS AGE ED SES FREQ B2 1.0 DL .08 1.0 PD .34 - . 3 2 1.0 IM . 47 - . 0 7 - . 1 2 1.0 B l .36 .24 .22 .15 1.0 ATQ .63 .18 - . 0 2 .60 .66 1.0 HS . 56 .21 - . 01 .44 .68 .86 1.0 DAS .15 .05 - . 2 5 .08 .46 .47 .71 1.0 AGE-.25 - . 4 9 .41- - .20 - . 08 - . 3 0 - .52 - . 4 7 1.0 ED - . 2 3 - . 1 4 - . 2 2 .38 - .31 .09 .07 .12 - . 1 0 1.0 SES-.03 .19 .03 - .19 .05 - . 1 4 - . 29 - . 4 6 .22-- .47 1.0 FREQ.06 .01 - . 1 7 .13 - . 19 - . 0 9 .14 .13 - . 21 .09 - . 4 9 1.0 Table 3 correlations of Measures for the Nondepressed Group B2 DL PD IM Bl ATQ HS DAS AGE ED SES FREQ B2 1.0 DL .36 1.0 PD --.29 - .10 1.0 IM --.32 - .13 -.10 1.0 Bl .52 .12 - .40- .50 1.0 ATQ .46 .26 - . 41 - .34 .75 1.0 • -HS --.07 -.12 - .27- .23 -.03 - .06 1.0 DAS .38 .08 - .20- .29 .29 .34 .34 1.0 AGE .01 .16 .21 .32 -.45 -.32 .01 - .05 1.0 .1, 214 ED -.11 .03 .30 .00-.48 -.15 .21 -.01 .34 1.0 SES .26 -.24 .08-.23 .37 -.03-.23 -.07 .09-.09 1.0 FREQ.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 1.0 Note . B2 = Time 2 Beck Depression Inventory scores. DL = Composite score from the dichotlc l i s t e n i n g task derived from reaction times of depression words -reaction times of positive words. PD = Composite score from the probe detection task derived from reaction times of depression words - reaction times of positive words. IM = Composite score from the i m p l i c i t memory task derived from depression words generated that were previously rated - positive words generated that were previously r a t e d . Bl = Time 1 Beck Depression Inventory scores. ATQ= Automatic Thoughts Questionnaire scores. HS = Hopelessness Scale scores. DAS= Dysfunctional Attitude Scale scores. AGE= Age in years. ED = Number of years of education. SES= Socioeconomic status ratings based on Blishen and McRoberts ( 1 9 7 6 ) . FREQ=frequency of previous depressive episode. 

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